Fast-forward to 40 minutes – soldier with severe maxillofacial trauma has scalpel-finger-tube cricothyroidotomy performed under IM ketamine in the back of a Blackhawk
The authors of a recent study tried to answer this question. The authors evaluated patients who got needle decompression in the field using prospective, observational methodology (though I wonder if truly prospective given the lack of data). Anyways, they noted that in their population very few patients (5/52 decompressions) escaped without requiring a follow-up chest tube. Only 1/15 penetrating trauma patients did not get a chest tube. A few important questions remain including how many of the needle decompressions actually reached the pleural cavity or the technique used for decompression (appears later in Q&A that it was probably anterior axillary line).
The authors conclude to have a low threshold for chest tube insertion based on CXR however, not shockingly a CT chest will provide more information. This study certainly doesn’t support withholding a chest drain if needle decompression is performed in the field. There was a nice suggesting by another surgeon who commented they leave all the needles in place during CT scan to see if it actually reached the pleural cavity. For the stable patient that doesn’t need immediate intervention, this is probably sound advice. Wait for the CT then make decision based on clinical and radiographic data.
There should probably be further study on this topic but for now, this is all we have! Here’s the abstract below.
Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax? KM Dominguez et al. Am J Surg 2013; 205(3): 329-332
Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tubethoracostomy is not required.
A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center.
Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]).
Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.
One of the perennial debates in medicine is the choice between a surgical technique versus a needle technique for a can’t intubate/can’t ventilate situation.
The video below shows Minh Le Cong demonstrating some approaches to needle cricothyroidotomy. What struck me was the how simple and fast the ‘minimalist’ approach is , whereby oxygenation is provided (very rapidly) by simply pressing the oxygen tubing up against the cannula hub – no furious hunting for suitable connection devices!
This is worth seeing, it looks like a very useful ‘get out of jail’ card! In the prehospital setting it could be a bridge to further attempts at laryngoscopy (in the podcast above Minh describes several occasions where this has occurred in a retrieval setting) or a more definitive surgical airway prior to transport.