Have we been waiting for this!
Courtesy of The Intensive Care Network – here is Dr Brian Burns (Greater Sydney Area HEMS) speaking at SMACC 2013 on prehospital procedures…
Click HERE for the audio (right click to open this in a new tab)
Accompanying slides below:
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.
While traditional teaching is that resuscitation on scene in traumatic cardiac arrest is futile, recent studies have demonstrated higher survival rates than previously thought.
The authors (UK emergency medicine and aeromedical specialists) of this paper have reviewed the literature regarding traumatic cardiac arrest and generated an algorithm that is applicable to both pre-hospital and hospital settings.
“The algorithm aims to rapidly identify and correct reversible causes of TCA. Transport of TCA patients from the pre-hospital to hospital setting with on-going cardiopulmonary resuscitation is usually futile and key interventions need to be performed as soon as possible, usually on-scene. Patients arriving at a hospital in traumatic peri- or cardiac arrest need reversible causes immediately excluded and managed prior to transfer for diagnostic imaging or surgical intervention. The treatment priorities in this algorithm have been applied by a physician-led pre-hospital trauma service to over a thousand TCA’s attended over an eighteen year period. Published results demonstrate that adherence to these principles can result in good survival rates from TCA.”
The algorithm focuses on treatment of reversible pathology that may have led to an arrest:
- Correction of hypovolaemia
- Decompression of tension pneumothorax
- Thoracotomy in the setting of penetrating chest/epigastric trauma
- Consideration of non-traumatic causes of cardiac arrest
Full text pdf of this paper is available here (secure area limited to ADHB staff only – ADHB has online subscription access to this journal via the Philson Library at the University of Auckland School of Medicine)