What the evidence shows:

Finger ThoracostomyVs

Chest Tube Insertion Vs

Needle Decompression

Cynthia Griffin D.O., EMT-PUniversity of Wisconsin MedFlight Fellow 2014

April 21, 2015

Objectives

• Review a quick history of trauma chest decompression

• Review the procedure, pathophysiology, & complications that can occur with needle thoracostomy (NT) while reviewing the literature

• Discuss if NT mandates tube thoracostomy (TT)• Review the prehospital literature on NT vs TT• Review the simple thoracostomy (ST) procedure

and the literature behind this• Discussion and Questions

M. Fitzgerald et al. Injury, Int. J. Care Injured (2008) 39, 9—20

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

German Study N=54N=51

N=111

N=110

N=1

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

Injury, Int. J. Care Injured (2008) 39, 9—20 Emerg Med J (2005);22:788

N=25

http://3.bp.blogspot.com/-D7PpDFIofPc/VLT_ikG0v-I/AAAAAAAAJTM/ERLVw5aSsCk/s1600/intercostal_space.jpg

N=75

“Generally safe and rapid procedure”

N=114

39 was 0.2% of their calls

“Judicious decompression prior to definitive care in the ED is a potentially life saving maneuver in the paramedics armamentarium”

N=39

Injury, Int. J. Care Injured (2008) 39, 9—20

Now, lets take a look at Chest Tubes…

Picture courtesyof Mr Ian Civil

Picture courtesy of Mr Adrian Pick

Injury, Int. J. Care Injured (2008) 39, 9—20

N=1

N=51

“78% w neg CXR initially s/p NT developed PTX of which 2 were tPTX”

“The laws of physics dictate that the clinician should consider PTX expansion as a risk assoc. w intratransportascent and decreasing ambient pressure”

N=66

belly

“With proper technique we consider pre-hospital TT to be a safe technique for the Rx of suspected tPTX w/out increased risk of iatrogenic injury.”

N=76

“There was no significant difference in the rate of malposition in the on scene vs in hospital placed chest tubes”

N = 24scene, 77 ED

“NT generally safe and rapid rx for tPTX in field TT should be adjunctive if NT fails & can be performed w out complications or worsening outcomes”

“TT was associated with less DOA, than NT”

N=106 TT, 169 NT

“Aeromedical crews appear to appropriately select MTVs to undergo field NT or TT. “

N = 136

“Swine model of thoracic insufflation showed NT w High failure rate for relief of tension physiology & for Rx of the tPTX induced PEA which was due to both mechanical failure & inadequate evacuation.”

N=40

“Prehospital use of TT by qualified professionals does not introduce additional risks of complications compared w/in Hosp therefore is a lifesaving & valuable addition to prehospitalcare.”

N > 162

• TT on scene vs ED

• “There appeared to be no differences between chest tubes inserted in the emergency room or at the scene”

• Beware of the complications with TT ~13

http://www.trauma.org/archive/thoracic/images/chestdrain01.jpg http://www.trauma.org/archive/thoracic/CHESTdrain.html

N=45

“Demonstrated ST to be a safe & effective method of chest drainage without major complications or infections related to field thoracostomy. Moreover, no recurrent tension PNX occurred”

N=55

“Finger Thoracostomy” 10-30-2013

Summary of Recommendations

• Not all rushes of air means NT is successful.

• NT has limitations although may be used as a temporizing measure.

• Decompression with breaching the pleural space is definitive treatment for tPTX.

• Giving them the finger with ST has data supporting this as effective and safe.

References

• Biewener A, Aschenbrenner U, Rammelt S, Grass R, Zwipp H. Impact of helicopter transport and hospital level on mortality of polytrauma patients. J Trauma 2004; 56:94–98.

• Delooz HH. Training manual: emergency medicine residency. Leuven, Belgium: University Department of Emergency Medicine; 1991. [Context Link]

• Fitzgerald M et al. Pleural decompression and drainage during trauma reception and resuscitation. Injury, Int. J. Care Injured (2008) 39, 9—20

• Fuld H. Simple device for control of tension pneumothorax. BMJ. 1944;2:503.3

• http://www.ctsnet.org/article/history-thoracic-drainage-ancient-greeks-wound-sucking-drummers-digital-monitoring

• Ferrie et al. The right place in the right space. Awareness of Site of needle thoracosentesis. Emerg Med J 2002;19:176-177

• Ferrie E.P., Collum N., and McGovern S.: The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J 2005; 22: pp. 788-789

• Deakin C.D., Davies G., and Wilson A.: Simple Thoracostomy Avoids Chest Drain Insertion in Prehospital Trauma. J Trauma 1995; 39: pp. 373-374

• Heng K., Bystrzycki A., Fitzgerald M., et al: Complications of intercostal catheter insertion using EMST techniques for chest trauma ANZ. J Surg 2004; 74: pp. 420-423

• Beckett A, Savage E, Pannell D, et al. Needle Decompression for Tension Pneumothorax in Tactical Combat Casualty Care: Do Catheters Placed in the Midaxillary Line Kink More Often Than Those in the Midclavicular Line? The Journal of Trauma: Injury, Infection, and Critical Care 2011;71:S408–12. doi:10.1097/TA.0b013e318232e558 [PMID 22071996]

• S. Bitten, S.H. Palmer, T.M. Snow. Needle thoracocentesis in tension pneumothorax; insufficient cannula length and potential failures, Injury, 27 (1996), pp321-322

• Givens ML. Needle Thoracostomy: Implications of Computed Tomography Chest Wall Thickness. Academic Emergency Medicine 2004;11:211–3. doi:10.1197/j.aem.2003.09.015 [PMID 14759970]

• Stevens RL, Rochester AA, Busko J, et al. Needle Thoracostomy for Tension Pneumothorax: Failure Predicted by Chest Computed Tomography. Prehosp Emerg Care 2009;13:14–7. doi:10.1080/10903120802471998 [PMID 19145519]

• download.springer.com/static/pdf/222/art%253A10.1007%252Fs00134-014-3434-1.pdf?auth66=1425310437_db07b031374ad1de2ee348ad76bab12e&ext=.pdf

• Waydhas C, Sauerland S. Prehospital Decompression for Susupected Tension Pneumothorax, Resuscitation 2007, Jan;72 (1) 11-25 Epub 2006 Nov 22. PMID: 17118508

• Herron H et al. Prehospital Decompression for Suspected Tension Pneumothorax. Air Medical Journal: 14:2, April-June 1995

• Eckstein M., Suyehara D. Needle Thoracostomy in the PreHospital Setting. Prehospital Emergency Care 1998;2:132-135

• Warner KJ, Copass MK, Bulger EM. Paramedic Use of Needle Thoracostomy in the prehospital environment. Prehospital emergency care, vol 12 number 2, april/june 2008

• Leigh-Smith S., and Harris T.: Tension pneumothorax, time for a rethink? Emerg Med J 2005; 22: pp. 8-16

• Beards S.C., and Lipman J.: Decreased cardiac index as an indicator of tension pneumothorax in the ventilated patient. Anaesthesia 1994; 49: pp. 137-141

• Struck MF et al. Bilateral False-Positive Tube Thoracostomy in Helicopter Emergency Medical Services. Air Medical Journal Assoc. Editorial 2015

• Paul AO et al. Malfunction of a Heimlich flutter valve causing tension pneumothorax: case report of a rare complication. Patient Safety in Surgery. 2010:10;8

• Dominguez KM et al. Is routine thoracostomy necessary after prehospital need decompression for tension pneumothorax?. American Journal of Surgery (2013) 205: pp 329-332

• Braude D, Tutera D, Tawil I, Pirkl G. Air transport of patients with pneumothorax: is tube thoracostomy required before flight?. Air Med J. 2014 Jul-Aug;33(4):152-6. doi: 10.1016/j.amj.2014.04.009.

• Knotts D et al. Pneumothorax Volume Expansion in Helicopter Emergency Medical Services Transport. Air Medical Journal 32:3, 2013

• Schmidt, U et al. Chest Tube Decompression of Blunt Chest Injuries by Physicians in Field: Effectiveness and Complications. Journal of Trauma-Injury Infection & Critical Care Jan 1998, Vol 44 Issue 1 pp98-100

• Huber-Wagner S, et al. Emergency Chest Tube Placement in Trauma Care – Which approach is preferable? Resuscitation June 28 2006

• Barton, ED, Epperson, M, Hoyt, BD, Fortiage, D, Rosen P. PreHospital Needle aspiration and tube thoracostomy in trauma victims: a six year experience with aeromedical crews. Journal of Emergency Medicine Vol 13, No 2, pp155-161; 1995

• Davis, D et al. The safety and efficacy of prehospital needle and tube thoracostomy by aeromedical personnel. Prehospital Emergency Care [1090-3127] Davis yr:2005 vol:9 iss:2 pg:191 -7

• Martin M., Satterly S., Inaba K., Blair K. Does Needle Thoracostomy provide adequate and effective decompression of tension pneumothorax? Journal of Trauma Acute Care Surgery 2012

• Spanjersberg W et al. Prehospital Chest Tube Thoracostomy: Effective treatment or Additional Trauma? Journal of Trauma-Injury Infection & Critical Care. July 2005, Vol 59 Issue 1, pp96-101

• Aylwn CJ et al. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Engl 2008;90:54-57

• Waydhas C, Sauerland S. Pre-Hospital pleural decompression and chest tube placement after blunt trauma: a systematic review. Resuscitation 2006

• Deakin C.D., Davies G., Wilson A. Simple Thoracostomy avoids chest drain insertion in Prehospital Trauma. The Journal of trauma: Injury, Infection and Critical Care. Vol 39 (2), August 1995, pp 373-374

• Massuratti D, et al. Simple thoracostomy in prehospital trauma management is safe and effective: a 2 yr experience by helicopter emergency medical crews, European Journal of Emergency Medicine Vol 13 No 5. 2006 ,pp276-280

• Karrer A., et al. Simple Thoracostomy: Moving Beyond Needle Decompressionin Traumatic Cardiac Arrest. Journal of mergency Medical Services. 3-28-2014

• Weingart S. “Finger Thoracostomy Podcast” emcrit.org 10-30-2013

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