What the evidence
shows:
Finger Thoracostomy
Vs
Chest Tube Insertion
Vs
Needle Decompression
Cynthia Griffin D.O., EMT-P
University 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
N=51
German Study N=54
N=1
N=110
N=111
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
N=25
Injury, Int. J. Care Injured (2008) 39, 9—20
Emerg Med J (2005);22:788
http://3.bp.blogspot.com/-D7PpDFIofPc/VLT_ikG0vI/AAAAAAAAJTM/ERLVw5aSsCk/s1600/intercostal_space.jpg
N=75
“Generally safe and rapid procedure”
N=114
“Judicious
decompression
prior to definitive
care in the ED is a
potentially life
saving maneuver
in the paramedics
armamentarium”
N=39
Now, lets take a look at Chest Tubes…
Injury, Int. J. Care Injured (2008) 39, 9—20
Picture courtesy of
Mr Adrian Pick
Picture courtesy
of Mr Ian Civil
Injury, Int. J. Care Injured (2008) 39, 9—20
N=1
“78% w neg CXR initially s/p NT
developed PTX of which 2 were tPTX”
N=51
N=66
“The laws of physics dictate
that the clinician should
consider PTX expansion as a
risk assoc. w intratransport
ascent and decreasing ambient
pressure”
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 prehospital
care.”
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
N=45
http://www.trauma.org/archive/thoracic/images/chestdrain01.jpg
http://www.trauma.org/archive/thoracic/CHESTdrain.html
“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.
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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 373374
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
References
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