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Helsloot D, Fitzgerald MC, Lefering R, Verelst S, Missant C. The first hour of trauma reception is critical for patients with major thoracic trauma: A retrospective analysis from the TraumaRegister DGU. Eur J Anaesthesiol 2023; 40:865-873. [PMID: 37139941 PMCID: PMC10552823 DOI: 10.1097/eja.0000000000001834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Up to 25% of trauma deaths are related to thoracic injuries. OBJECTIVE The primary goal was to analyse the incidence and time distribution of death in adult patients with major thoracic injuries. The secondary goal was to determine if potentially preventable deaths occurred within this time distribution and, if so, identify an associated therapeutic window. DESIGN Retrospective observational analysis. SETTING TraumaRegister DGU. PATIENTS Major thoracic injury was defined as an Abbreviated Injury Scale (AIS) 3 or greater. Patients with severe head injury (AIS ≥ 4) or injuries to other body regions with AIS being greater than the thoracic injury (AIS other >AIS thorax) were excluded to ensure that the most severe injury described was primarily thoracic related. MAIN OUTCOME MEASURES Incidence and time distribution of mortality were considered the primary outcome measures. Patient and clinical characteristics and resuscitative interventions were analysed in relation to the time distribution of death. RESULTS Among adult major trauma cases with direct admission from the accident scene, 45% had thoracic injuries and overall mortality was 9.3%. In those with major thoracic trauma ( n = 24 332) mortality was 5.9% ( n = 1437). About 25% of these deaths occurred within the first hour after admission and 48% within the first day. No peak in late mortality was seen. The highest incidences of hypoxia and shock were seen in non-survivors with immediate death within 1 h and early death (1 to 6 h). These groups received the largest number of resuscitative interventions. Haemorrhage was the leading cause of death in these groups, whereas organ failure was the leading cause of death amongst those who survived the first 6 h after admission. CONCLUSION About half of adult major trauma cases had thoracic injuries. In non-survivors with primarily major thoracic trauma, most deaths occurred immediately (<1h) or within the first 6 h after injury. Further research should analyse if improvements in trauma resuscitation performed within this time frame will reduce preventable deaths. TRIAL REGISTRATION The present study is reported within the publication guidelines of the TraumaRegister DGU® and registered as TR-DGU project ID 2020-022.
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Affiliation(s)
- Dries Helsloot
- From the Department of Anaesthesiology & Emergency Medicine, AZ Groeninge Hospital (DH, CM), Department of Cardiovascular Sciences, KU Leuven University campus Kulak, Kortrijk, Belgium Kortrijk Campus, Kortrijk, Belgium (DH, CM), National Trauma Research Institute, Alfred Health & Monash University (DH, MCF), Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia (MCF), Institute for Research in Operative Medicine (IFOM), Universität Witten/Herdecke, Cologne, Germany (RL), Department of Emergency Medicine, UZ Leuven Hospital, (SV), Department of Public Health and Primary Care, KU Leuven University, Leuven, Belgium (SV), Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU)
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Sharrock MK, Shannon B, Garcia Gonzalez C, Clair TS, Mitra B, Noonan M, Fitzgerald PM, Olaussen A. Prehospital paramedic pleural decompression: A systematic review. Injury 2021; 52:2778-2786. [PMID: 34454722 DOI: 10.1016/j.injury.2021.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 02/02/2023]
Abstract
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 25th 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.
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Affiliation(s)
- Ms Kelsey Sharrock
- Department of Paramedicine, Monash University, Melbourne, Australia; Ambulance Victoria, Doncaster, Melbourne, Australia
| | - Brendan Shannon
- Department of Paramedicine, Monash University, Melbourne, Australia; Ambulance Victoria, Doncaster, Melbourne, Australia
| | | | - Toby St Clair
- Department of Paramedicine, Monash University, Melbourne, Australia; Ambulance Victoria, Doncaster, Melbourne, Australia; The Royal Children's Hospital, Department of Trauma, Melbourne, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; National Trauma Research Institute, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University
| | - Michael Noonan
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; National Trauma Research Institute, Melbourne, Australia
| | - Prof Mark Fitzgerald
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; National Trauma Research Institute, Melbourne, Australia; Central Clinical School, Monash University, Melbourne, Australia
| | - Alexander Olaussen
- Department of Paramedicine, Monash University, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; National Trauma Research Institute, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia.
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Hannon L, St Clair T, Smith K, Fitzgerald M, Mitra B, Olaussen A, Moloney J, Braitberg G, Judson R, Teague W, Quinn N, Kim Y, Bernard S. Finger thoracostomy in patients with chest trauma performed by paramedics on a helicopter emergency medical service. Emerg Med Australas 2020; 32:650-656. [PMID: 32564497 DOI: 10.1111/1742-6723.13549] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 04/08/2020] [Accepted: 04/27/2020] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Liam Hannon
- Ambulance Victoria, Melbourne, Victoria, Australia.,Emergency Department, Bendigo Health, Bendigo, Victoria, Australia
| | - Toby St Clair
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Trauma, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Ambulance Victoria, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - John Moloney
- Ambulance Victoria, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia
| | - George Braitberg
- Ambulance Victoria, Melbourne, Victoria, Australia.,Emergency Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rodney Judson
- Emergency Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Warwick Teague
- Department of Trauma, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nuala Quinn
- Department of Trauma, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Yesul Kim
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia
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Is Prehospital Time Important for the Treatment of Severely Injured Patients? A Matched-Triplet Analysis of 13,851 Patients from the TraumaRegister DGU®. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5936345. [PMID: 31321238 PMCID: PMC6610751 DOI: 10.1155/2019/5936345] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/11/2019] [Accepted: 05/16/2019] [Indexed: 11/17/2022]
Abstract
Background The impact of time (the golden period of trauma) on the outcome of severely injured patients has been well known for a long time. While the duration of the prehospital phase has changed only slightly (average time: ~66 min) since the TraumaRegister DGU® (TR-DGU®) was implemented, mortality rates have decreased within the last 20 years. This study analyzed the influence of prehospital time on the outcome of trauma patients in a matched-triplet analysis. Material and Methods A total of 93,024 patients from the TraumaRegister DGU® were selected based on the following inclusion criteria: ISS ≥ 16, primary admission, age ≥ 16 years, and data were available for the following variables: prehospital intubation, blood pressure, mode of transportation, and age. The patients were assigned to one of three groups: group 1: 10-50 min (short emergency treatment time); group 2: 51-75 min (intermediate emergency treatment time); group 3: >75 min (long emergency treatment time). A matched-triplet analysis was conducted; matching was based on the following criteria: intubation at the accident site, rescue resources, Abbreviated Injury Scale (AIS) of the body regions, systolic blood pressure, year of the accident, and age. Results A total of 4,617 patients per group could be matched. The number of patients with a GCS score ≤8 was significantly higher in the first group (group 1: 36.6%, group 2: 33.5%, group 3: 30.3%; p < 0.001). Moreover, the number of patients who had to be resuscitated during the prehospital phase and/or upon arrival at the hospital was higher in group 1 (p = 0.010); these patients also had a significantly higher mortality (group 1: 20.4%, group 2: 18.1%, group 3: 15.9%; p ≤ 0.001). The number of measures performed during the prehospital phase (e.g., chest tube insertion) increased with treatment time. Conclusions The results suggest that survival after severe trauma is not only a matter of short rescue time but more a matter of well-used rescue time including performance of vital measures already in the prehospital setting. This also includes that rescue teams identify the severity of injuries more rapidly in the most-severely injured patients in critical condition than in less-severely injured patients and plan their interventions accordingly.
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Ventzke MM, Segitz O, Kemming GI. Entlastung des Spannungspneumothorax. Notf Rett Med 2018. [DOI: 10.1007/s10049-018-0519-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Raatiniemi L, Brattebø G. The challenge of ambulance missions to patients not in need of emergency medical care. Acta Anaesthesiol Scand 2018. [PMID: 29520763 DOI: 10.1111/aas.13103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L. Raatiniemi
- Centre for Pre-Hospital Emergency Care; Oulu University Hospital; Oulu Finland
- Anaesthesia Research Group; MRC, Oulu University Hospital and University of Oulu; Oulu Finland
| | - G. Brattebø
- Department of Anaesthesia & Intensive Care; Haukeland University Hospital; Bergen Norway
- Norwegian National Advisory Unit on Trauma; Division of Emergencies and Critical Care; Oslo University Hospital; Oslo Norway
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Outcomes of a Clinical Pathway for Pleural Disease Management: "Pleural Pathway". Pulm Med 2018; 2018:2035248. [PMID: 29805807 PMCID: PMC5899858 DOI: 10.1155/2018/2035248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Clinical pathways are evidence based multidisciplinary team approaches to optimize patient care. Pleural diseases are common and accounted for 3.4 billion US $ in 2014 US inpatient aggregate charges (HCUPnet data). An institutional clinical pathway ("pleural pathway") was implemented in conjunction with a dedicated pleural service. Design, implementation, and outcomes of the pleural pathway (from August 1, 2014, to July 31, 2015) in comparison to a previous era (from August 1, 2013, to July 31, 2014) are described. Methods Tuality Healthcare is a 215-bed community healthcare system in Hillsboro, OR, USA. With the objective of standardizing pleural disease care, locally adapted British Thoracic Society guidelines and a centralized pleural service were implemented in the "pathway" era. System-wide consensus regarding institutional guidelines for care of pleural disease was achieved. Preimplementation activities included training, acquisition of ultrasound equipment, and system-wide education. An audit database was set up with the intent of prospective audits. An administrative database was used for harvesting outcomes data and comparing them with the "prior to pathway" era. Results 54 unique consults were performed. A total of 55 ultrasound examinations and 60 pleural procedures were performed. All-cause inpatient pleural admissions were lower in the "pathway" era (n = 9) compared to the "prior to pathway" era (n = 17). Gains in average case charges (21,737$ versus 18,818.2$/case) and average length of stay (3.65 versus 2.78 days/case) were seen in the "pathway" era. Conclusion A "pleural pathway" and a centralized pleural service are associated with reduction in case charges, inpatient admissions, and length of stay for pleural conditions.
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Drinhaus H, Annecke T, Hinkelbein J. [Chest decompression in emergency medicine and intensive care]. Anaesthesist 2017; 65:768-775. [PMID: 27629501 DOI: 10.1007/s00101-016-0219-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Decompression of the chest is a life-saving invasive procedure for tension pneumothorax, trauma-associated cardiopulmonary resuscitation or massive haematopneumothorax that every emergency physician or intensivist must master. Particularly in the preclinical setting, indication must be restricted to urgent cases, but in these cases chest decompression must be executed without delay, even in subpar circumstances. The methods available are needle decompression or thoracentesis via mini-thoracotomy with or without insertion of a chest tube in the midclavicular line of the 2nd/3rd intercostal space (Monaldi-position) or in the anterior to mid-axillary line of the 4th/5th intercostal space (Bülau-position). Needle decompression is quick and does not require much material, but should be regarded as a temporary measure. Due to insufficient length of the usual 14-gauge intravenous catheters, the pleural cavity cannot be reached in a considerable percentage of patients. In the case of mini-thoracotomy, one must be cautious not to penetrate the chest inferior of the mammillary level, to employ blunt dissection techniques, to clearly identify the pleural space with a finger and not to use a trocar. In extremely urgent cases opening the pleural membrane by thoracostomy without inserting a chest tube is sufficient in mechanically ventilated patients. Complications are common and mainly include ectopic positions, which can jeopardise effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as haemorrhage or infections. By respecting the basic rules for safe chest decompression many of these complications should be avoidable.
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Affiliation(s)
- H Drinhaus
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland.
| | - T Annecke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland
| | - J Hinkelbein
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland
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Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg 2016; 80:272-7. [PMID: 26670108 DOI: 10.1097/ta.0000000000000889] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Decompression of tension physiology may be lifesaving, but significant doubts remain regarding ideal needle thoracostomy (NT) catheter length in the treatment of tension physiology. We aimed to demonstrate increased clinical effectiveness of longer NT angiocatheter (8 cm) compared with current Advanced Trauma Life Support recommendations of 5-cm NT length. METHODS This is a retrospective review of all adult trauma patients from 2003 to 2013 (age > 15 years) transported to a Level I trauma center. Patients underwent NT at the second intercostal space midclavicular line, either at the scene of injury, during transport (prehospital), or during initial hospital trauma resuscitation. Before March 2011, both prehospital and hospital trauma team NT equipment routinely had a 5-cm angiocatheter available. After March 2011, prehospital providers were provided an 8-cm angiocatheter. Effectiveness was defined as documented clinical improvement in respiratory, cardiovascular, or general clinical condition. RESULTS There were 91 NTs performed on 70 patients (21 bilateral placements) either in the field (prehospital, n = 41) or as part of resuscitation in the hospital (hospital, n = 29). Effectiveness of NT was 48% until March 2011 (n = 24). NT effectiveness was significantly higher in the prehospital setting than in the hospital (68.3% success rate vs. 20.7%, p < 0.01). Patients who underwent NT using 8 cm compared with 5 cm were significantly more effective (83% vs. 41%, respectively, p = 0.01). No complications of NT were identified in either group. CONCLUSION Eight-centimeter angiocatheters are more effective at chest decompression compared with currently recommended 5 cm at the second intercostal space midclavicular line. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Chen J, Nadler R, Schwartz D, Tien H, Cap AP, Glassberg E. Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience. Can J Surg 2015; 58:S118-24. [PMID: 26100771 DOI: 10.1503/cjs.012914] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Point of injury needle thoracostomy (NT) for tension pneumothorax is potentially lifesaving. Recent data raised concerns regarding the efficacy of conventional NT devices. Owing to these considerations, the Israeli Defense Forces Medical Corps (IDF-MC) recently introduced a longer, wider, more durable catheter for the performance of rapid chest decompression. The present series represents the IDF-MC experience with chest decompression by NT. METHODS We reviewed the IDF trauma registry from January 1997 to October 2012 to identify all cases in which NT was attempted. RESULTS During the study period a total of 111 patients underwent chest decompression by NT. Most casualties (54%) were wounded as a result of gunshot wounds (GSW); motor vehicle accidents (MVAs) were the second leading cause (16%). Most (79%) NTs were performed at the point of injury, while the rest were performed during evacuation by ambulance or helicopter (13% and 4%, respectively). Decreased breath sounds on the affected side were one of the most frequent clinical indications for NT, recorded in 28% of cases. Decreased breath sounds were more common in surviving than in nonsurviving patients. (37% v. 19%, p < 0.001). A chest tube was installed on the field in 35 patients (32%), all after NT. CONCLUSION Standard NT has a high failure rate on the battlefield. Alternative measures for chest decompression, such as the Vygon catheter, appear to be a feasible alternative to conventional NT.
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Affiliation(s)
- Jacob Chen
- The IDF Medical Corps, the Department of Surgery, Rabin Medical Center, Beilinson Campus, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel and the US Army Institute of Surgical Research, Fort Sam, Houston, Texas
| | | | - Dagan Schwartz
- The IDF Medical Corps, the Department of Emergency Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Homer Tien
- The Canadian Forces Health Services, the 1 Canadian Field Hospital, Petawawa, Ont., the Trauma Services and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Andrew P Cap
- The US Army Institute of Surgical Research, Fort Sam, Houston, Texas
| | - Elon Glassberg
- The IDF Medical Corps, the Trauma & Combat Medicine Branch, Surgeon General's HQ, Israel Defense Forces, Ramat Gan, Israel
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