Failure rate of prehospital chest decompression after severe thoracic trauma

Diagnostic performance of prehospital EFAST in predicting CT scan injuries in severe trauma patients: a multicenter cohort study

BACKGROUND

The early mortality of trauma patients, mainly from hemorrhagic shock, raises interest in detecting the presence of non-exteriorized bleeding. Intra-hospital EFAST (Extended Focused Assessment with Sonography for Trauma) has demonstrated its utility in the assessment and management of severe trauma patients (STP). However, there is a lack of data regarding the diagnostic performance of prehospital EFAST (pEFAST). The main objective of our study was to evaluate the pEFAST performance to predict a positive CT scan in STP.

METHODS

This was a retrospective, multicenter, database-driven study. All severe trauma patients managed by a prehospital medical team were included. The results of pEFAST were compared with the admission CT scan.

RESULTS

Data from 495 patients were included. The pEFAST had sensitivity of 27% (95% CI 22; 32) and specificity of 94% (95% CI 90; 97) for predicting the presence of a lesion on CT scan at hospital admission. The area under the curve (AUC) was 0.66 (95% CI 0.57; 0.63), the positive predictive value 84% (95% CI 75; 87), the negative predictive value was 51% (95% CI 44; 66), the positive likelihood ratio was 4.24 (95% CI 2.46; 7.3) and the negative likelihood ratio 0.78 (95% CI 0.72; 0.85).

CONCLUSION

Prehospital EFAST has an excellent specificity but a poor sensitivity for predicting a positive CT scan on hospital admission. We do not know whether this low sensitivity is secondary to the delay between the two examinations or to the poor performance of pEFAST. Therefore, a negative pEFAST should not be reassuring. A positive pEFAST is highly informative, as it predicts a lesion and enables hospital management to be prepared accordingly.

Prehospital Trauma Compendium: Traumatic Pneumothorax Care - a position statement and resource document of NAEMSP

Emergency Medical Services (EMS) clinicians manage patients with traumatic pneumothoraces. These may be simple pneumothoraces that are less clinically impactful, or tension pneumothoraces that disturb perfusion, lead to shock, and impart significant risk for morbidity and mortality. Needle thoracostomy is the most common EMS treatment of tension pneumothorax, but despite the potentially life-saving value of needle thoracostomy, reports indicate frequent misapplication of the procedure as well as low rates of successful decompression. This has led some to question the value of prehospital needle thoracostomy and has prompted consideration of alternative approaches to management (e.g., simple thoracostomy, tube thoracostomy). EMS clinicians must determine when pleural decompression is indicated and optimize the safety and effectiveness of the procedure. Further, there is also ambiguity regarding EMS management of open pneumothoraces. To provide evidence-based guidance on the management of traumatic pneumothoraces in the EMS setting, NAEMSP performed a structured literature review and developed the following recommendations supported by the evidence summarized in the accompanying resource document.NAEMSP recommends:EMS identification of a tension pneumothorax must be guided by a combination of risk factors and physical findings, which may be augmented by diagnostic technologies.EMS clinicians should recognize the differences in the clinical presentation of a tension pneumothorax in spontaneously breathing patients and in patients receiving positive pressure ventilation.EMS clinicians should not perform pleural decompression in patients with simple pneumothoraces but should perform pleural decompression in patients with tension pneumothorax, if within the clinician's scope of practice.When within scope of practice, EMS clinicians should use needle thoracostomy as the primary strategy for pleural decompression of tension pneumothorax in most cases. EMS clinicians should take a patient-individualized approach to performing needle thoracostomy, influenced by factors known to impact chest wall thickness and risk for iatrogenic injury.Simple thoracostomy and tube thoracostomy may be used by highly trained EMS clinicians in select clinical settings with appropriate medical oversight and quality assurance.EMS systems must investigate and adopt strategies to confirm successful pleural decompression at the time thoracostomy is performed.Pleural decompression should be performed for patients with traumatic out-of-hospital circulatory arrest (TOHCA) if there are clinical signs of tension pneumothorax or suspicion thereof due to significant thoraco-abdominal trauma. Empiric bilateral decompression, however, is not routinely indicated in the absence of such findings.EMS clinicians should not routinely perform pleural decompression of suspected or confirmed simple pneumothorax prior to air-medical transport in most situations.EMS clinicians may consider placement of a vented chest seal in spontaneously breathing patients with open pneumothoraces.In patients receiving positive pressure ventilation who have open pneumothoraces, chest seals may be harmful and are not recommended.EMS physicians play an important role in developing curricula and leading quality management programs to both ensure that EMS clinicians are properly trained in the recognition and management of tension pneumothorax and to ensure that interventions for tension pneumothorax are performed appropriately, safely, and effectively.

Needlessly Treated: Evaluation of Prehospital Needle Thoracostomy

BACKGROUND

Needle thoracostomy is a potentially life-saving intervention for tension pneumothorax but may be overused, potentially leading to unnecessary morbidity.

OBJECTIVE

To review prehospital needle thoracostomy indications, effectiveness, and adverse outcomes.

METHODS

A retrospective cohort study was conducted based on registry data for a United States Midwestern Level I trauma center for a 7.5-year period (January 2015 to May 2022). Included were patients who received prehospital needle thoracostomy and trauma activation before hospital arrival. The primary outcomes were correct indications and improvement in vital signs. Secondary outcomes were the need for chest tubes, correct needle placement, complications, and survival.

RESULTS

A total of n = 67 patients were reviewed, of which n = 63 (94%) received a prehospital thoracostomy. Of the 63 prehospital thoracostomies, 54 (86%) survived to arrival. Of these 54, 44 (n = 81%) had documented reduced/absent breath sounds, 15 (28%) hypotension, and 19 (35%) with difficulty breathing/ventilating. Only four patients met all three prehospital trauma life support criteria: hypotension, difficulty ventilating, and absent breath sounds. There were no significant changes in prehospital vitals before and after receiving needle thoracostomy. In patients receiving imaging (n = 54), there was evidence of 15 (28%) lung lacerations, 6 (11%) of which had a pneumothorax and 3 (5%) near misses of important structures. Review of needle catheters visible on computer tomography imaging found 11 outside the chest and 1 in the abdominal cavity.

CONCLUSION

The study presents evidence of potential needle thoracostomy overuse and morbidity. Adherence to specific guidelines for needle decompression is needed.

The Perfect Med Bag is One that Doesn't Fall Off a Cliff: A Combat Mass Casualty Case

Military trauma provides a unique pattern of injuries due to the high velocity, high kinetic energy ammunition utilized, and the high prevalence of blast injury. To further complicate this, military trauma often occurs in austere environments with limited logistical support. Therefore, military medical providers are forced to learn nonstandard techniques and when necessary, practice a level of improvisation not commonly seen in other medical fields. The case presented in this manuscript is a prime example of these challenges. At the onset of fighting both the medic's rucksack, carrying with it the primary source of medical gear and the precious supply of cold-stored blood products are lost. The scenario was further complicated by rough mountainous terrain and a prolonged evacuation time. The medical provider was forced to utilize nonstandard devices such as an improvised junctional tourniquet which used a rock to focus the devices pressure. They also adapted their basic understanding of surgical procedures to conduct a vascular cutdown procedure for wound exposure and effectively pack an otherwise non-compressible wound to a major artery. Despite a significant loss of equipment, the medic and their team were able to successfully care for a number of patients in this mass casualty scenario.

A Pilot Study on the Role of Experience and Patient Gender on MARCH Treatment Sequence

INTRODUCTION

The brevity of training for soldiers and combat medics to learn how to provide treatment on the battlefield may restrict optimal performance for treating chest and airway injuries, particularly when treating female soldiers. The present study tested treatment performance on patient simulators by battlefield medic trainees to determine whether there is a need for more extensive training on chest and airway procedures on female soldiers.

MATERIALS AND METHODS

Battlefield medic trainees treated male and female patient simulators in counterbalanced order. The assessment considered the effects of patient gender and order on procedures performed, particularly critical chest and airway interventions such as needle chest decompression (NCD), and considered the appropriate order of treatment tasks. Four coders rated video footage of three simulated procedures, i.e., tourniquet, chest seal (front and back application), and NCD, using a binary coding system to determine completeness and order correctness according to the Massive hemorrhage, Airway, Respiration, Circulation, and Head injury/Hypothermia (MARCH) mnemonic.

RESULTS

Results from analysis of variance showed that when presented with a female patient first, trainees performed significantly fewer total procedures on both the female and male simulators. More experienced trainees completed significantly more procedures compared to trainees with minimal experience. Results from the binary logistic regression showed that trainees with more experience and trainees presented with the male patient simulator first performed significantly more procedures in the correct order. Finally, an examination of the NCD procedure found that trainees presented with the female patient simulator first had more errors and that trainees with less experience were less likely to perform the procedure adequately.

CONCLUSIONS

The findings suggest that treating a female patient first may lead to undertreatment of both patients. Furthermore, the observed differences in treating sensitive areas of the body (e.g., near female breasts) suggest providing greater opportunities for trainees to practice often missed or incorrectly performed procedures. Treating a female patient remains a novel experience for many trainees, such that trainees are less likely to fully treat a female patient and are less likely to treat female soldiers for the most life-threatening injuries. In fact, the initial presentation of the female patient simulator appeared to affect experienced trainees, suggesting that removing the experience of novelty and stress requires more extensive exposure and alternative training. The study's small sample size with a wide range of trainee experience may limit the findings, which may fail to capture some study effects. Finally, the study did not request trainees' experience treating female soldiers, so future studies should examine the extent to which experience is predictive of performance. There is a need for more interactive approaches in patient simulations to provide opportunities for practice, especially those that require the treatment of sensitive areas.

Experience of Health Professionals in Caring for Patients With Chest Trauma: A Qualitative Study

BACKGROUND

The variation in the implementation of chest trauma (CT) management's guidelines led to inconsistent and mixed experiences toward CT management by the health care team. Moreover, there is a scarcity of studies exploring factors that enhance CT management experiences worldwide and in Jordan.

OBJECTIVES

The aims of this study were (1) to explore emergency health professionals' attitudes and experiences toward CT management and (2) to understand factors that affect the care for patients with CTs among emergency health professionals.

METHODS

A qualitative exploratory approach was adopted in this study. Individual, semistructured, face-to-face interviews were conducted with 30 emergency health professionals (physicians, nurses, and paramedics) from government emergency departments, military, private hospitals, and paramedics from the Civil Defense in Jordan.

RESULTS

The results showed that emergency health professionals had negative attitudes toward caring for patients with CTs due to a lack of knowledge and clarity in their job description and duties assigned to them. Moreover, some organizational and training factors were discussed for their impact on the attitudes of emergency health professionals toward caring for patients with CTs.

CONCLUSIONS

Lack of knowledge, absence of clear guidelines and job descriptions for dealing with traumas, and lack of continuous training on caring for patients with CTs were the most common reasons for negative attitudes. These findings can assist stakeholders, managers, and organizational leaders in understanding health care challenges and provoke a more focused strategic plan to diagnose and treat patients with CT.

[Chest Tube in Thoracic Trauma - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU)]

For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH₂O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.

A Comparison of Tube Thoracostomy for Chest Trauma Between Prehospital and Inhospital Settings

OBJECTIVE

We compared the outcomes of patients with tube thoracostomy for chest trauma between the prehospital and inhospital settings.

METHODS

The subjects were then divided into 2 groups: the prehospital group, which included subjects who underwent tube thoracostomy in the prehospital setting, and the inhospital group, which included subjects who underwent tube thoracostomy in the inhospital setting. The variables were compared between the 2 groups.

RESULTS

There were no significant differences between the 2 groups with regard to gender, age, history, mechanism of injury, infusion of antibiotics, white blood cell count, duration of insertion of a chest drain, mechanical ventilation, complication of drain infection, duration of admission, or final outcome. However, the Injury Severity Score, maximum C-reactive protein level, and maximum temperature during hospitalization in the prehospital group (n = 15) were significantly greater than those in the inhospital group (n = 119).

CONCLUSION

The present study suggested that thoracostomy performed by physicians in the prehospital setting was safe and did not have an increased risk of infection. In addition, thoracostomy for chest injury in the prehospital setting suggested an improvement in the likelihood of a survival outcome.

Prehospital decompression of tension pneumothorax: Have we moved the needle?

BACKGROUND

Needle thoracostomy (NT) is the first-line intervention for tension pneumothorax in the prehospital setting. This study examined the effect of ATLS curriculum and EMS protocol changes on patient selection and successful performance of the procedure.

METHODS

This is a retrospective chart review of all patients presenting to a Level One Trauma Center from 2015 to 2020 after undergoing prehospital NT.

RESULTS

Lateral NT placement increased significantly from 5.1% to 38.9%. Proper patient selection, defined as presence decompensated shock, respiratory distress, and diminished breath sounds increased from 23.1% to 27.8%. There was no difference in radiographic confirmation of the catheter in the pleural space. Iatrogenic injury rates decreased slightly from 28.2% to 16.7%.

CONCLUSIONS

Protocol and curriculum changes have fallen short in yielding improved NT success rates or patient selection. Continued development of EMS education on the performance of NT is indicated.

Association of Prehospital Needle Decompression With Mortality Among Injured Patients Requiring Emergency Chest Decompression

Importance

Prehospital needle decompression (PHND) is a rare but potentially life-saving procedure. Prior studies on chest decompression in trauma patients have been small, limited to single institutions or emergency medical services (EMS) agencies, and lacked appropriate comparator groups, making the effectiveness of this intervention uncertain.

Objective

To determine the association of PHND with early mortality in patients requiring emergent chest decompression.

Design, Setting, and Participants

This was a retrospective cohort study conducted from January 1, 2000, to March 18, 2020, using the Pennsylvania Trauma Outcomes Study database. Patients older than 15 years who were transported from the scene of injury were included in the analysis. Data were analyzed between April 28, 2021, and September 18, 2021.

Exposures

Patients without PHND but undergoing tube thoracostomy within 15 minutes of arrival at the trauma center were the comparison group that may have benefited from PHND.

Main Outcomes and Measures

Mixed-effect logistic regression was used to determine the variability in PHND between patient and EMS agency factors, as well as the association between risk-adjusted 24-hour mortality and PHND, accounting for clustering by center and year. Propensity score matching, instrumental variable analysis using EMS agency-level PHND proportion, and several sensitivity analyses were performed to address potential bias.

Results

A total of 8469 patients were included in this study; 1337 patients (11%) had PHND (median [IQR] age, 37 [25-52] years; 1096 male patients [82.0%]), and 7132 patients (84.2%) had emergent tube thoracostomy (median [IQR] age, 32 [23-48] years; 6083 male patients [85.3%]). PHND rates were stable over the study period between 0.2% and 0.5%. Patient factors accounted for 43% of the variation in PHND rates, whereas EMS agency accounted for 57% of the variation. PHND was associated with a 25% decrease in odds of 24-hour mortality (odds ratio [OR], 0.75; 95% CI, 0.61-0.94; P = .01). Similar results were found in patients who survived their ED stay (OR, 0.68; 95% CI, 0.52-0.89; P < .01), excluding severe traumatic brain injury (OR, 0.65; 95% CI, 0.45-0.95; P = .03), and restricted to patients with severe chest injury (OR, 0.72; 95% CI, 0.55-0.93; P = .01). PHND was also associated with lower odds of 24-hour mortality after propensity matching (OR, 0.79; 95% CI, 0.62-0.98; P = .04) when restricting matches to the same EMS agency (OR, 0.74; 95% CI, 0.56-0.99; P = .04) and in instrumental variable probit regression (coefficient, -0.60; 95% CI, -1.04 to -0.16; P < .01).

Conclusions and Relevance

In this cohort study, PHND was associated with lower 24-hour mortality compared with emergent trauma center chest tube placement in trauma patients. Although performed rarely, PHND can be a life-saving intervention and should be reinforced in EMS education for appropriately selected trauma patients.

Post-mortem computed tomography assessment of medical support device position following fatal trauma: a single-center experience

PURPOSE

To evaluate the percentage of misplaced medical support lines and tubes in deceased trauma patients using post-mortem computed tomography (PMCT).

METHODS

Over a 9-year period, trauma patients who died at or soon after arrival in the emergency department were candidates for inclusion. Whole body CT was performed without contrast with support medical devices left in place. Injury severity score (ISS) was calculated by the trauma registrar based on the injuries identified on PMCT. The location of support medical devices was documented in the finalized radiology reports.

RESULTS

A total of 87 decedents underwent PMCT, of which 69% (n = 60) were male. For ten decedents, the age was unknown. For the remaining 77 decedents, the average age was 48.4 years (range 18-96). The average ISS for the cohort was 43.4. Each decedent had an average of 3.3 support devices (2.9-3.6, 95% CI), of which an average of 1 (31.3%, 0.8-1.2, 95% CI) was malpositioned. A total of 60 (69.0%) had at least one malpositioned medical support device. The most commonly malpositioned devices were decompressive needle thoracostomies (n = 25/32, 78.1%). The least malpositioned devices were intraosseous catheters (n = 7/69, 10.1%). Nearly one quarter (n = 19/82, 23.2%) of mechanical airways were malpositioned, including 4.9% with esophageal intubation.

CONCLUSION

Malpositioned supportive medical devices are commonly identified on post-mortem computed tomography trauma decedents, seen in 69.0% of the cohort, including nearly one quarter with malpositioned mechanical airways. Post-mortem CT can serve as a useful adjunct in the quality improvement process by providing data for education of trauma and emergency physicians and first responders.

Prehospital portable ultrasound for safe and accurate prehospital needle thoracostomy: a pilot educational study

Background

Simulated needle thoracostomy (NT) using ultrasound may reduce potential injury, increase accuracy, and be as rapid to perform as the traditional landmark technique following a brief educational session. Our objective was to determine if the use of an educational session demonstrating the use of handheld ultrasound to Emergency Medical Services (EMS) staff to facilitate NT was both feasible, and an effective way of increasing the safety and efficacy of this procedure for rural EMS providers.

Methods

A pre/post-educational intervention on a convenience sample of rural North American EMS paramedics and nurses. Measurement of location and estimated depth of placement of needle thoracostomy with traditional landmark technique was completed and then repeated using handheld ultrasound following a training session on thoracic ultrasound and correct placement of NT.

Results

A total of 30 EMS practitioners participated. Seven were female (23.3%). There was a higher frequency of dangerous structures underlying the chosen location with the landmark technique 9/60 (15%) compared to the ultrasound technique 1/60 (1.7%) (p = 0.08). Mean time-to-site-selection for the landmark technique was shorter than the ultrasound technique at 10.7 s (range 3.35–45 s) vs. 19.9 s (range 7.8–50 s), respectively (p < 0.001). There was a lower proportion of correct location selection for the landmark technique 40/60 (66.7%) when compared to the ultrasound technique 51/60 (85%) (p = 0.019). With ultrasound, there was less variance between the estimated and measured depth of the pleural space with a mean difference of 0.033 cm (range 0–0.5 cm) when ultrasound was used as compared to a mean difference of 1.0375 cm (range 0–6 cm) for the landmark technique (95% CI for the difference 0.73–1.27 cm; p < 0.001).

Conclusions

Teaching ultrasound NT was feasible in our cohort. While time-to-site-selection for ultrasound-guided NT took longer than the landmark technique, it increased safe and accurate simulated NT placement with fewer identified potential iatrogenic injuries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00270-w.

Fifteen-minute consultation: A guide to the paediatric primary survey

It's 21:00 and you receive a stand-by call from the local ambulance service. Peter, a 9-year-old boy, was riding an electric scooter and has collided with a car. He has reduced consciousness, signs of shock and is hypoxic. How will you prepare your team? What are the possible injuries? Who will perform the primary survey? Injury is the leading cause of morbidity and mortality in the paediatric population accounting for approximately half of all attendances to paediatric emergency departments in the UK and Ireland. Major trauma can be distressing for patients, parents and physicians. Managing major trauma is challenging and it is vital to have a clear and organised approach. In this 15-minute guide we describe a structured approach to the primary survey that includes how to prepare before the child's arrival, the suggested roles of team members and the key components of the primary survey. We discuss life-threatening injuries, the life-saving bundle and the principles of resuscitation, and the role of imaging in the initial assessment of the injured child.

To Watch Before or Listen While Doing? A Randomized Pilot of Video-Modelling versus Telementored Tube Thoracostomy

BACKGROUND

New care paradigms are required to enable remote life-saving interventions (RLSIs) in extreme environments such as disaster settings. Informatics may assist through just-in-time expert remote-telementoring (RTM) or video-modelling (VM). Currently, RTM relies on real-time communication that may not be reliable in some locations, especially if communications fail. Neither technique has been extensively developed however, and both may be required to be performed by inexperienced providers to save lives. A pilot comparison was thus conducted.

METHODS

Procedure-naïve Search-and-Rescue Technicians (SAR-Techs) performed a tube-thoracostomy (TT) on a surgical simulator, randomly allocated to RTM or VM. The VM group watched a pre-prepared video illustrating TT immediately prior, while the RTM group were remotely guided by an expert in real-time. Standard outcomes included success, safety, and tube-security for the TT procedure.

RESULTS

There were no differences in experience between the groups. Of the 13 SAR-Techs randomized to VM, 12/13 (92%) placed the TT successfully, safely, and secured it properly, while 100% (11/11) of the TT placed by the RTM group were successful, safe, and secure. Statistically, there was no difference (P = 1.000) between RTM or VM in safety, success, or tube security. However, with VM, one subject cut himself, one did not puncture the pleura, and one had barely adequate placement. There were no such issues in the mentored group. Total time was significantly faster using RTM (P = .02). However, if time-to-watch was discounted, VM was quicker (P = .000).

CONCLUSIONS

Random evaluation revealed both paradigms have attributes. If VM can be utilized during "travel-time," it is quicker but without facilitating "trouble shooting." On the other hand, RTM had no errors in TT placement and facilitated guidance and remediation by the mentor, presumably avoiding failure, increasing safety, and potentially providing psychological support. Ultimately, both techniques appear to have merit and may be complementary, justifying continued research into the human-factors of performing RLSIs in extreme environments that are likely needed in natural and man-made disasters.

Complications associated with pre-hospital open thoracostomies: a rapid review

Background

Open thoracostomies have become the standard of care in pre-hospital critical care in patients with chest injuries receiving positive pressure ventilation. The procedure has embedded itself as a rapid method to decompress air or fluid in the chest cavity since its original description in 1995, with a complication rate equal to or better than the out-of-hospital insertion of indwelling pleural catheters. A literature review was performed to explore potential negative implications of open thoracostomies and discuss its role in mechanically ventilated patients without clinical features of pneumothorax.

Main findings

A rapid review of key healthcare databases showed a significant rate of complications associated with pre-hospital open thoracostomies. Of 352 thoracostomies included in the final analysis, 10.6% (n = 38) led to complications of which most were related to operator error or infection (n = 26). Pneumothoraces were missed in 2.2% (n = 8) of all cases.

Conclusion

There is an appreciable complication rate associated with pre-hospital open thoracostomy. Based on a risk/benefit decision for individual patients, it may be appropriate to withhold intervention in the absence of clinical features, but consideration must be given to the environment where the patient will be monitored during care and transfer. Chest ultrasound can be an effective assessment adjunct to rule in pneumothorax, and may have a role in mitigating the rate of missed cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00976-1.

Sound and Air: Ultrasonographic Measurements of Pediatric Chest Wall Thickness and Implications for Needle Decompression of Tension Pneumothorax

OBJECTIVES

Needle decompression is potentially life-saving in cases of tension pneumothorax. Although Advanced Trauma Life Support recommends an 8-cm needle for decompression for adults, no detailed pediatric guidelines exist, specifically regarding needle length or site of decompression.

METHODS

Point-of-care ultrasound was used to measure chest wall thickness (CWT), the distance between skin and pleural line, bilaterally at the second intercostal midclavicular line and the fourth intercostal anterior axillary line in children of various ages and sizes. Patients were grouped based on Broselow tape weight categories. Measurements were compared between left versus right sides at the 2 anatomic sites. Interclass correlation coefficients were calculated to assess for interrater reliability.

RESULTS

A convenience sample of 163 patients from our emergency department was enrolled. For patients who fit into Broselow tape categories, CWT at the second intercostal midclavicular line ranged from 1.11 to 1.91 cm and at the fourth intercostal anterior axillary line ranged from 1.13 to 1.92 cm. In patients larger than the largest Broselow category, 77% had a CWT less than the length of a standard 1.25-in (3.175 cm) catheter. There were no significant differences in the measurements of CWT based on laterality nor anatomic site.

CONCLUSIONS

The standard 1.25-in (3.175 cm) catheters are sufficient to treat most tension pneumothoraces in pediatric patients.

Prehospital paramedic pleural decompression: A systematic review

BACKGROUND

Tension pneumothorax (TPT) is a frequent life-threat following thoracic injury. Time-critical decompression of the pleural cavity improves survival. However, whilst paramedics utilise needle thoracostomy (NT) and/or finger thoracostomy (FT) in the prehospital setting, the superiority of one technique over the other remains unknown.

AIM

To determine and compare procedural success, complications and mortality between NT and FT for treatment of a suspected TPT when performed by paramedics.

METHODS

We searched four databases (Ovid Medline, PubMed, CINAHL and Embase) from their commencement until 25^th August 2020. Studies were included if they analysed patients suffering from a suspected TPT who were treated in the prehospital setting with a NT or FT by paramedics (or local equivalent nonphysicians).

RESULTS

The search yielded 293 articles after duplicates were removed of which 19 were included for final analysis. Seventeen studies were retrospective (8 cohort; 7 case series; 2 case control) and two were prospective cohort studies. Only one study was comparative, and none were randomised controlled trials. Most studies were conducted in the USA (n=13) and the remaining in Australia (n=4), Switzerland (n=1) and Canada (n=1). Mortality ranged from 12.5% to 79% for NT and 64.7% to 92.9% for FT patients. A higher proportion of complications were reported among patients managed with NT (13.7%) compared to FT (4.8%). We extracted three common themes from the papers of what constituted as a successful pleural decompression; vital signs improvement, successful pleural cavity access and absence of TPT at hospital arrival.

CONCLUSION

Evidence surrounding prehospital pleural decompression of a TPT by paramedics is limited. Available literature suggests that both FT and NT are safe for pleural decompression, however both procedures have associated complications. Additional high-quality evidence and comparative studies investigating the outcomes of interest is necessary to determine if and which procedure is superior in the prehospital setting.

Trends in combat casualty care following the publication of clinical practice guidelines

BACKGROUND

The current study explores the trends in the application of combat casualty care following the publication of clinical practice guidelines (CPGs) in five domains for 13 years.

METHODS

The Israel Defense Forces Trauma Registry was used to assess practice and adherence to guidelines in five domains: (a) crystalloid transfusions, (b) tranexamic acid use, (c) freeze-dried plasma use, (d) chest decompression, and (e) airway management. All patients injured between January 2006 and December 2018 were included in the analysis. Trends were analyzed and presented monthly using linear regression and were compared using the Chow test.

RESULTS

The mean ± SD crystalloid volume transfused decreased from 1,179 ± 653 mL in 2006 to 466 ± 202 mL in 2018 (B = 0.016, 0.006-0.044). The proportion of patients with an indication treated with tranexamic acid dropped from 8% (238 of 2,979 patients) to 2.5% (60 of 2,356 patients) following the stricter guideline's publication. Freeze-dried plasma administration in indicated casualties rose from 12.5% in 2013 to 48% in 2018 (B = 1.63, 1.3-2.05). The overall proportion of casualties undergoing chest decompression rose from 1% (61 of 6,036 casualties) to 1.5% (155 of 10,493 casualties) following the release of a new CPG in 2012 (p = 0.013). There were no significant trends in intubation ratios before (B = 0.987, 0.953-1.02) or after 2012 (B = 10.2, 0.996-1.05).

CONCLUSION

Some aspects demonstrate the desired trends in response to new CPGs; in others, initial improvement is achieved but followed by stagnation. In some medical care aspects, completely unexpected and undesirable trends are observed. Every change and update in CPGs should be based on reliable data. The effect of every change must be monitored carefully to ensure adequate adherence to lifesaving guidelines.

LEVEL OF EVIDENCE

Epidemiological study, level IV.

Prehospital Decompression of Pneumothorax: A Systematic Review of Recent Evidence

INTRODUCTION

Pneumothorax remains an important cause of preventable trauma death. The aim of this systematic review is to synthesize the recent evidence on the efficacy, patient outcomes, and adverse events of different chest decompression approaches relevant to the out-of-hospital setting.

METHODS

A comprehensive literature search was performed using five databases (from January 1, 2014 through June 15, 2020). To be considered eligible, studies required to report original data on decompression of suspected or proven traumatic pneumothorax and be considered relevant to the prehospital context. They also required to be conducted mostly on an adult population (expected more than ≥80% of the population ≥16 years old) of patients. Needle chest decompression (NCD), finger thoracostomy (FT), and tube thoracostomy were considered. No meta-analysis was performed. Level of evidence was assigned using the Harbour and Miller system.

RESULTS

A total of 1,420 citations were obtained by the search strategy, of which 20 studies were included. Overall, the level of evidence was low. Eleven studies reported on the efficacy and patient outcomes following chest decompression. The most studied technique was NCD (n = 7), followed by FT (n = 5). Definitions of a successful chest decompression were heterogeneous. Subjective improvement following NCD ranged between 18% and 86% (n = 6). Successful FT was reported for between 9.7% and 32.0% of interventions following a traumatic cardiac arrest. Adverse events were infrequently reported. Nine studies presented only on anatomical measures with predicted failure and success. The mean anterior chest wall thickness (CWT) was larger than the lateral CWT in all studies except one. The predicted success rate of NCD ranged between 90% and 100% when using needle >7cm (n = 7) both for the lateral and anterior approaches. The reported risk of iatrogenic injuries was higher for the lateral approach, mostly on the left side because of the proximity with the heart.

CONCLUSIONS

Based on observational studies with a low level of evidence, prehospital NCD should be performed using a needle >7cm length with either a lateral or anterior approach. While FT is an interesting diagnostic and therapeutic approach, evidence on the success rates and complications is limited. High-quality studies are required to determine the optimal chest decompression approach applicable in the out-of-hospital setting.

Thoracic Endotracheal Tube Insertion During Prehospital Thoracostomy: A Case Report

This case highlights the novel use of endotracheal tubes to maintain patency of simple thoracostomies (STs) performed to relieve a tension pneumothorax after failed needle thoracostomy (NT). Treatment of a tension pneumothorax in the prehospital setting is typically performed using NT because of the minimal equipment required and rapid application. However, the variable efficacy of NT has led to a rise in the use of ST as an alternative procedure to treat a tension pneumothorax. A potential complication of ST is the occlusion of the thoracostomy site, which, left unresolved, may lead to the reoccurrence of tension physiology. In a resource-rich setting, such as in a hospital, the ST would be followed by tube thoracostomy to ensure patency. Unfortunately, this may not be feasible in prehospital environments where constraints exist because of time, equipment, and personnel. A review of the literature surrounding prehospital ST reveals previous reports of endotracheal tubes being used to maintain patency temporarily. However, no cases documenting the successful use of this novel procedure in an air medical setting were found at the time of writing. This case documents the successful use of this novel procedure during the treatment of a polytraumatized adult female resulting from a motorcycle crash.

Clinical Characteristics of Patients Undergoing Needle Thoracostomy in a Canadian Helicopter Emergency Medical Service

Objective: Needle thoracostomy (NT) can be a life-saving procedure when used to treat tension pneumothorax. However, there is some question regarding the efficacy of NT in the prehospital setting. Failure to treat tension pneumothorax in a helicopter emergency medical service (HEMS) setting may prove especially deleterious to the patient due to gas expansion with increasing altitude. This study's objective was to identify the characteristics of patients treated with NT in a Canadian HEMS setting and the factors that may influence outcomes following NT use.Methods: This was a retrospective chart review of prehospital records from a Canadian HEMS service. Patients aged 18 years and older who underwent at least one NT attempt using a 14-gauge 8.3 cm needle from 2012 to 2018 were identified. Charts were reviewed to collect demographic data, NT procedural characteristics, vital signs, and clinical response metrics. Descriptive statistics were used to characterize the study sample and overall event characteristics. Binary logistic regression was performed to identify variables associated with a clinical response to the initial NT treatment.Results: 163 patients (1.3%) of 12,407 patients attended received NT. A positive clinical response to NT was recorded in 37% (n = 77) of the total events (n = 208), the most common of which was an improvement in blood pressure (BP) (18.8%, n = 39). Initial NT was associated with a low likelihood of clinical improvement in patients presenting with blunt trauma (OR = 0.18; p = .021; 95% CI [.04, .77]), CPR prior to NT (OR = 0.14; p = .02; 95% CI [.03, .73]), or in those who received bilateral NT treatment (OR = 0.13; p < .01; 95% CI [.05, .37]). A pretreatment BP < 90 mmHg was predictive of a positive clinical response to initial NT (OR = 3.33; p = .04; 95% CI [1.09, 10.20]).Conclusions: Only a small portion of patients in the setting of a Canadian HEMS service were treated with NT. Patients most likely to receive NT were males who had suffered blunt trauma. NT may have questionable benefit for patients presenting with blunt trauma, in cardiac arrest, or requiring bilateral NT.

Sonographic evaluation of chest wall thickness in Chinese adults in Hong Kong: Should the updated (10th edition) Advance Trauma Life Support guidelines on preferred site of needle thoracocentesis in tension pneumothorax be adopted in the Asian population?

Objective

To compare the anterior with lateral mean chest wall thickness measured by bedside ultrasound in Chinese adults in order to suggest a preferred site for needle decompression in tension pneumothorax.

Study design

This was an observational cross-sectional study conducted in a regional hospital over three months. Subjects were recruited by convenience sampling. Chest wall thickness at the second intercostal space, mid clavicular line, fifth intercostal space, anterior axillary line and fifth intercostal space and mid axillary line was measured using ultrasound on both sides. Range, mean values and confidence intervals were calculated.

Results

One-hundred and fourteen subjects were recruited. The mean anterior chest wall thickness was 2.62 cm (at second intercostal space, mid-clavicular line) and mean lateral chest wall was 2.68 cm (at fifth intercostal space, anterior axillary line) and 2.87 cm (at fifth intercostal space and mid-axillary line) respectively. Chest wall thickness at fifth intercostal space and mid-axillary line was significantly greater than second intercostal space, mid-clavicular line ( p < 0.01). Chest wall thickness was greater than 5 cm in 3.5% of the study population.

Conclusion

There is a need for population-based guidelines. We recommend needle decompression at the second intercostal space, mid-clavicular line with a 50-mm angiocath for Chinese patients with tension pneumothorax. A lateral approach at the fifth intercostal space, anterior axillary line may be considered as an alternative in case of failure. Prehospital point-of-care ultrasound may be a useful adjunct in managing such patients.

Finger thoracostomy in patients with chest trauma performed by paramedics on a helicopter emergency medical service

OBJECTIVE

To determine the frequency of finger thoracostomy performed by intensive care flight paramedics after the introduction of a training programme in this procedure and complications of the procedure that were diagnosed after hospital arrival.

METHODS

This was a retrospective cohort study of adult and paediatric trauma patients undergoing finger thoracostomy performed by paramedics on a helicopter emergency medical service between June 2015 and May 2018. Hospital data were obtained through a manual search of the medical records at each of the three receiving major trauma services. Additional data were sourced from the Victorian State Trauma Registry.

RESULTS

The final analysis included 103 cases, of which 73.8% underwent bilateral procedures with a total of 179 finger thoracostomies performed. The mean age of patients was 42.8 (standard deviation 21.4) years and 73.8% were male. Motor vehicle collision was the most common mechanism of injury accounting for 54.4% of cases. The median Injury Severity Score was 41 (interquartile range 29-54). There were 30 patients who died pre-hospital, with most (n = 25) having finger thoracostomy performed in the setting of a traumatic cardiac arrest. A supine chest X-ray was performed prior to intercostal catheter insertion in 38 of 73 patients arriving at hospital; of these, none demonstrated a tension pneumothorax. There were three cases of potential complications related to the finger thoracostomy.

CONCLUSION

Finger thoracostomy was frequently performed by intensive care flight paramedics. It was associated with a low rate of major complications and given the deficiencies of needle thoracostomy, should be the preferred approach for chest decompression.

Complications from Needle Thoracostomy: Penetration of the Myocardium

We report a rare but serious complication of needle thoracostomy, penetration of the myocardium. Needle thoracostomy is typically performed in the prehospital setting or upon arrival in the emergency department for suspected tension pneumothorax. Needle decompression is generally taught and done anteriorly, in the 2^nd intercostal space on the midclavicular line (MCL). An alternative approach is laterally, along the anterior axillary line (AAL) in the 4^th intercostal space. Our case supports prior literature that the anterior MCL location has a low rate of efficacy to decompress the chest, as well as a high rate of complications. We recommend performing needle decompression laterally at the AAL whether in the field or in the emergency department.

Augmenting prehospital care

INTRODUCTION

The challenging environment of prehospital casualty care demands providers to make prompt decisions and to engage in lifesaving interventions, occasionally without them being adequately experienced. Telementoring based on augmented reality (AR) devices has the potential to decrease the decision time and minimise the distance gap between an experienced consultant and the first responder. The purpose of this study was to determine whether telementoring with AR glasses would affect chest thoracotomy performance and self-confidence of inexperienced trainees.

METHODS

Two groups of inexperienced medical students performed a chest thoracotomy in an ex vivo pig model. While one group was mentored remotely using HoloLens AR glasses, the second performed the procedure independently. An observer assessed the trainees' performance. In addition, trainees and mentors evaluated their own performance.

RESULTS

Quality of performance was found to be superior with remote guidance, without significant prolongation of the procedure (492 s vs 496 s, p=0.943). Moreover, sense of self-confidence among participant was substantially improved in the telementoring group in which 100% of the participants believed the procedure was successful compared with 40% in the control group (p=0.035).

CONCLUSION

AR devices may have a role in future prehospital telementoring systems, to provide accessible consultation for first responders, and could thus positively affect the provider's confidence in decision-making, enhance procedure performance and ultimately improve patient prognosis. That being said, future studies are required to estimate full potential of this technology and additional adjustments are necessary for maximal optimisation and implementation in the field of prehospital care.

Pre-hospital trauma care in Switzerland and Germany: do they speak the same language?

Purpose

Swiss and German (pre-)hospital systems, distribution and organization of trauma centres differ from each other. It is unclear if outcome in trauma patients differs as well. Therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both German-speaking countries.

Methods

The TraumaRegister DGU^® (TR-DGU) was used. Patients with Injury Severity Score ≥ 9 admitted to a level 1 trauma centre between 01/2009 and 12/2017 were included if they required ICU care or died. Trauma pattern, pre-hospital procedures and outcome were compared between Swiss (CH, n = 4768) and German (DE, n = 66,908) groups.

Results

Swiss patients were older than German patients (53 vs. 50 years). ISS did not differ between groups (CH 23.8 vs. DE 23.0 points). There were more low falls < 3 m (34% vs. 21%) at the expense of less traffic accidents (37% vs. 52%) in the Swiss population. In Switzerland 30% of allocations were done without physician involvement, whereas this occurred in 4% of German cases. Despite a comparable number of patients with a GCS ≤ 8 (CH 29.6%; DE 26.4%), differences in pre-hospital intubation rates occurred (CH 31% vs. DE 40%). Severe traumatic brain injuries were diagnosed most frequently in Switzerland (CH 62% vs. DE 49%). Admission vital signs were similar, and standardized mortality ratios were close to one in both countries.

Conclusion

This study demonstrates that patients’ age, trauma patterns and pre-hospital care differ between Germany and Switzerland. However, adjusted mortality was almost similar. Further benchmarking studies are indicated to optimize trauma care in both German-speaking countries.

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

OBJECTIVE

Thoracic trauma is a leading cause of paediatric trauma deaths. Traumatic cardiac arrest, tension pneumothorax and massive haemothorax are life-threatening conditions requiring emergency and definitive pleural decompression. In adults, thoracostomy is increasingly preferred over needle thoracocentesis for emergency pleural decompression. The present study reports on the early experience of thoracostomy in children, to inform debate regarding the best approach for emergency pleural compression in paediatric trauma.

METHODS

Retrospective review of Ambulance Victoria and The Royal Children's Hospital Melbourne, Trauma Registry between August 2016 and February 2019 to identify children undergoing thoracostomy for trauma, either pre-hospital or in the ED.

RESULTS

Fourteen children aged 1.2-15 years underwent 23 thoracostomy procedures over the 31 month period. The majority of patients sustained transport-related injuries, and underwent thoracostomies for the primary indications of hypoxia and hypotension. Two children were in traumatic cardiac arrest. Ten children underwent needle thoracocentesis prior to thoracostomy, but all required thoracostomy to achieve the necessary definitive decompression. All patients were severely injured with multiple-associated serious injuries and median Injury Severity Score 35.5 (17-75), three of whom died from their injuries. Thoracostomy in our cohort had a low complication rate.

CONCLUSION

In severely injured children, thoracostomy is an effective and reliable method to achieve emergency pleural decompression, including in the young child. The technical challenges presented by children are real, but can be addressed by training to support a low complication rate. We recommend thoracostomy over needle thoracocentesis as the first-line intervention in children with traumatic cardiac arrest, tension pneumothorax and massive haemothorax. [Correction added on 23 September 2019 after first online publication: in the second sentence of the conclusion, the words "under review process" were mistakenly added and have been removed.].

Potentially preventable trauma deaths: A retrospective review

BACKGROUND

Reviewing prehospital trauma deaths provides an opportunity to identify system improvements that may reduce trauma mortality. The objective of this study was to identify the number and rate of potentially preventable trauma deaths through expert panel reviews of prehospital and early in-hospital trauma deaths.

METHODS

We conducted a retrospective review of prehospital and early in-hospital (<24 h) trauma deaths following a traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria (AV) in the state of Victoria, Australia, between 2008 and 2014. Expert panels were used to review cases that had resuscitation attempted by paramedics and underwent a full autopsy. Patients with a mechanism of hanging, drowning or those with anatomical injuries deemed to be unsurvivable were excluded.

RESULTS

Of the 1183 cases that underwent full autopsies, resuscitation was attempted by paramedics in 336 (28%) cases. Of these, 113 cases (34%) were deemed to have potentially survivable injuries and underwent expert panel review. There were 90 (80%) deaths that were not preventable, 19 (17%) potentially preventable deaths and 4 (3%) preventable deaths. Potentially preventable or preventable deaths represented 20% of those cases that underwent review and 7% of cases that had attempted resuscitation.

CONCLUSIONS

The number of potentially preventable or preventable trauma deaths in the pre-hospital and early in-hospital resuscitation phase was low. Specific circumstances were identified in which the trauma system could be further improved.

Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography

Objective: Needle thoracostomy is a life-saving procedure. Advanced Trauma Life Support guidelines recommend insertion of a 5 cm, 14-gauge needle for pneumothorax decompression. High-risk complications can arise if utilizing an inappropriate needle size. No study exist evaluating appropriate needle length in pediatric patients. Utilizing computed tomography (CT), we determined the needle length required to access the pleural cavity in children matched to Broselow™ Pediatric Emergency Tape color. Methods: Three investigators reviewed chest CTs of children <13 years of age obtained between 2010 and 2015. Patient exclusions included those with a chest wall mass, muscle disease, pectus deformity, anasarca, prior open thoracotomy, inadequate imaging, or missing height documentation. We established 4 groups based upon Broselow™ color as determined by recorded height. Investigators, trained by a pediatric board-certified radiologist, obtained standardized CT measurements of chest wall thickness at 4 points: right/left second intercostal space at the midclavicular line (ICS-MCL) and right/left fourth intercostal space in the anterior axillary line (ICS-AAL). Our outcome was the median chest wall thickness and 95% confidence intervals for each Broselow grouping and anatomic site. Results: A total of 273 chest CTs were reviewed, of which 23 were excluded, for a resultant study population of 250 scans and 498 total measurements. Median patient age was 4 years, 52.8% were male. Children measuring Broselow Gray/Pink (<68 cm), had a median chest wall thickness at the 2nd ICS-MCL of 1.57 cm (95% CI 1.42 cm, 1.72 cm), 4th ICS-AAL 1.67 cm (95% CI 1.48 cm, 1.86 cm). Broselow Red/Purple (68.1-90 cm): 2nd ICS-MCL of 1.96 cm (95% CI 1.84 cm, 2.08 cm), 4th ICS-AAL 1.73 cm (95% CI 1.62 cm, 1.84 cm). Broselow Yellow/White (90.1-115cm): 2nd ICS-MCL of 2.12 cm (95% CI 2.03 cm, 1.22 cm), 4th ICS-AAL 1.91 cm (95% CI 1.8 cm, 2.01 cm). Broselow Blue/Orange/Green (>115.1 cm): 2nd ICS-MCL of 2.45 cm (95% CI 2.3 cm, 2.6 cm), 4th ICS-AAL 2.19cm (95% CI 2.02 cm, 2.36 cm). Conclusion: Median chest wall thickness varies little by height or location in children <13 years of age. The standard 5-cm needle is twice the chest wall thickness of most children. Commercially available 14 g or 16 g standard-length 3.8 cm (1½ inch) needles are of adequate length to access the pleural cavity, regardless of height as measured by Broselow LBT.

Failure Rate of Prehospital Needle Decompression for Tension Pneumothorax in Trauma Patients

Tension pneumothorax is commonly treated with needle decompression (ND) at the 2nd intercostal space midclavicular line (2nd ICS MCL) but is thought to have a high failure rate. Few studies have attempted to directly measure the failure rate in patients receiving the intervention. We performed a retrospective analysis of 10 years of patients receiving prehospital ND. CT scans were reviewed to record the location of catheters left indwelling and the proportion of patients who did not have any pneumothorax. Chest wall thickness was measured on both injured and uninjured sides at the 2nd ICS MCL and compared with the recommended alternative, the 5th ICS anterior axillary line (5th ICS AAL). We identified 335 patients that underwent prehospital ND who had CT scans performed. Using our two different radiologic methods of assessing failure, 39 per cent and 76 per cent of attempts at ND failed to reach the pleural space. In addition, at least 39 per cent of patients did not have a tension pneumothorax. Injured chest walls were significantly thicker than uninjured chest walls at both the 2nd ICS MCL and the 5th ICS AAL (both P < 0.005.) Increasing chest wall thickness correlated with the failure of the catheter to reach the pleural space. Using an 8-cm catheter at the 5th ICS AAL, iatrogenic cardiac injury was at risk in 42 per cent of patients. This series confirms the high failure rate of ND at the 2nd ICS MCL, but further studies are needed to assure the safety of using larger catheters at the 5th ICS AAL.

Transoceanic Telementoring of Tube Thoracostomy Insertion: A Randomized Controlled Trial of Telementored Versus Unmentored Insertion of Tube Thoracostomy by Military Medical Technicians

Background: Tension pneumothorax is a frequent cause of potentially preventable death. Tube thoracostomy (TT) can obviate death but is invasive and fraught with complications even in experienced hands. We assessed the utility of a remote international virtual network (RIVN) of specialized mentors to remotely guide military medical technicians (medics) using wireless informatics. Methods: Medics were randomized to insert TT in training mannequins (TraumaMan; Abacus ALS, Meadowbrook, Australia) supervised by RIVN or not. The RIVN consisted of trauma surgeons in Canada and Australia and a senior medic in Ohio. Medics wore a helmet-mounted wireless camera with laser pointer to confirm anatomy and two-way voice communication using commercial software (Skype^®). Performance was measured through objective task completion (pass/fail) regarding safety during the procedure, proper location, and secure anchoring of the tube, in addition to remote mentor opinion and subjective debrief. Results: Fourteen medics attempted TT, seven mentored and seven not. The RIVN was functional and surgeons on either side of the globe had real-time communication with the mentees. TT placement was considered safe, successful, and secure in 100% of mentored (n = 7) procedures, although two (29%) received corrective remote guidance. All (100%) of the unmentored attempted and adequately secured the TT and were safe. However, only 71% (n = 5) completed the task successfully (p = 0.46). Participating medics subjectively felt remote telementoring (RTM) increased self-confidence (strong agreement mean 5/5 ± 0); confidence to perform field TT (agreement (4/5 ± 1); and decreased anxiety (strong agreement 5/5 ± 1). Subjectively, the remote mentors felt in 100% of the mentored procedures that "yes" they were able to assist the medics (1.86 ± 0.38), and in 71% (n = 5) felt "yes" they made TT safer (2.29 ± 0.49). Conclusions: RTM descriptively increased the success of TT placement and allowed for real-time troubleshooting from thousands of kilometers with a redundant capability. RTM was subjectively associated with high levels of satisfaction and self-reported self-confidence. Continued controlled and critical evaluation and refinement of telemedical techniques should continue. Trial Registration: ID ISRCTN/77929274.