Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review

Prehospital management of chest injuries in severely injured patients-a systematic review and clinical practice guideline update

PURPOSE

Our aim was to review and update the existing evidence-based and consensus-based recommendations for the management of chest injuries in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched to May 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies, and comparative registry studies were included if they compared interventions for the detection and management of chest injuries in severely injured patients in the prehospital setting. We considered patient-relevant clinical outcomes such as mortality and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Two new studies were identified, both investigating the accuracy of in-flight ultrasound in the detection of pneumothorax. Two new recommendations were developed, one recommendation was modified. One of the two new recommendations and the modified recommendation address the use of ultrasound for detecting traumatic pneumothorax. One new good (clinical) practice point (GPP) recommends the use of an appropriate vented dressing in the management of open pneumothorax. Eleven recommendations were confirmed as unchanged because no new high-level evidence was found to support a change.

CONCLUSION

Some evidence suggests that ultrasound should be considered to identify pneumothorax in the prehospital setting. Otherwise, the recommendations from 2016 remained unchanged.

Clinical outcomes of traumatic pneumothoraces undergoing conservative management following detection by prehospital physicians

OBJECTIVE

To describe the clinical and transport characteristics of patients diagnosed with a suspected traumatic pneumothorax and managed conservatively by prehospital medical teams including secondary deterioration during transfer and the subsequent rate of in-hospital tube thoracostomy.

METHODS

Retrospective observational study of all adult trauma patients diagnosed with a suspected pneumothorax on ultrasound and managed conservatively by their treating prehospital medical team between 2018 and 2020. Descriptive analysis was performed comparing patients who did and did not receive in-hospital tube thoracostomy.

RESULTS

In total, 181 patients were diagnosed with suspected traumatic pneumothoraces on prehospital ultrasound of which 75 (41.4%) were managed conservatively by their treating medical team whilst 106 (58.6%) underwent pleural decompression. There were no recorded cases of emergent pleural decompression required in transit. Of the 75 conservatively managed patients, 42 (56%) had an intercostal catheter (ICC) placed within four hours of hospital arrival and another nine (17.6%) had an ICC placed between four- and 24-hours post-hospital arrival. There was no significant difference in prehospital clinical characteristics between patients who did and did not receive an in-hospital ICC. The detection of a pneumothorax on the initial chest x-ray and larger pneumothorax volume visualised on computed tomography imaging were significantly more common in patients receiving in-hospital ICCs. Aviation factors including flight altitude and duration of flight were not associated with subsequent in-hospital tube thoracostomy.

CONCLUSION

Prehospital medical teams can safely identify patients who have a traumatic pneumothorax and can be transported to hospital without pleural decompression. Patient characteristics at the time of hospital arrival combined with the size of pneumothorax identified on imaging appear most likely to influence subsequent urgent in-hospital tube thoracostomy placement.

Traumatic pancreas, kidney, liver, spleen, gastric and diaphragma rupture with enterothorax after blunt trauma caused by falling in an adolescent: a case report

Injury of almost all intra-abdominal organs in blunt trauma without bone and brain injury is very rare. This is the case report of a 16-year-old adolescent with severe abdominal trauma who was hit on his abdomen by a falling maytree. After admission to a Level I trauma center, emergency room treatment according to ATLS and after this emergency surgery was performed. Blood coagulation diagnostics was done using thrombo-elastography and factors and blood products have been applied according to its results keeping guidelines in mind. Damage-control surgery stopped the bleeding, and he was admitted to ICU. After second and third look surgery, the abdomen was closed. Structured diagnostics and treatment were crucial in this case. The education of trauma surgeons should include general surgery skills. These skills and knowledge of blood coagulation diagnostics and therapy saved the patient's life in this case.

Mid‐Arm Point in PAEDiatrics (MAPPAED): An effective procedural aid for safe pleural decompression in trauma

OBJECTIVE

Life-threatening thoracic trauma requires emergency pleural decompression and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children can be challenging. We assessed whether the Mid-Arm Point (MAP) technique, a procedural aid proposed for use with injured adults, would also identify a safe site for pleural decompression in children.

METHODS

Children (0-18 years) attending four EDs were prospectively recruited. The MAP technique was performed, and chest wall skin marked bilaterally at the level of the MAP; no pleural decompression was performed. Radio-opaque markers were placed over the MAP-determined skin marks and corresponding intercostal space (ICS) reported using chest X-ray.

RESULTS

A total of 392 children participated, and 712 markers sited using the MAP technique were analysed. Eighty-three percentage of markers were sited within the 'safe zone' for pleural decompression (4th to 6th ICSs). When sited outside the 'safe zone', MAP-determined markers were typically too caudal. However, if the site for pleural decompression was transposed one ICS cranially in children ≥4 years, the MAP technique performance improved significantly with 91% within the 'safe zone'.

CONCLUSIONS

The MAP technique reliably determines a safe site for pleural decompression in children, albeit with an age-based adjustment, the Mid-Arm Point in PAEDiatrics (MAPPAED) rule: 'in children aged ≥4 years, use the MAP and go up one ICS to hit the safe zone. In children <4 years, use the MAP.' When together with this rule, the MAP technique will identify a site within the 'safe zone' in 9 out of 10 children.

Prehospital Simple Thoracostomy Does Not Improve Patient Outcomes Compared to Needle Thoracostomy in Severely Injured Trauma Patients

BACKGROUND

ATLS suggests simple thoracostomy (ST) after failure of needle thoracostomy (NT) in thoracic trauma. Some EMS agencies have adopted ST into their practice. We sought to describe our experience implementing ST in the prehospital setting, hypothesizing that prehospital ST would reduce failure rates and improve outcomes compared to NT.

METHODS

This was a retrospective review of adult trauma patients who received prehospital ST or NT from 2017 to 2020.

RESULTS

There were 48 patients with 64 procedures included. 83.7% were male and 65.8% injured by penetrating mechanism and of median (IQR) age of 31 (25-46) years. 28 (43.8%) procedures were NT and 36 (56.3%) were ST. Rates of improved patient response (P = .15), noted return of blood/air (P = .19), and return of spontaneous circulation (P = .62) did not differ. On-scene times were higher for ST (16.8 vs 11.5 minutes; P < .02). Overall mortality did not differ between ST and NT (68.2% vs 46.4%, respectively; P = .125). For patients that survived beyond the ED, procedure-related complication rates were 2 of 21 patients (9.5%) in ST and 1 of 12 (8.3%) in NT. In penetrating trauma, simple thoracostomy had longer on-scene time and total prehospital time.

DISCUSSION

ST did not improve success rates of ROSC and was associated with prolonged prehospital times, especially in penetrating trauma patients. Given the benefit of "scoop and run" in urban penetrating trauma, consideration should be given to direct transport in lieu of ST. Use of ST in blunt trauma should be evaluated prospectively.

An evidence-based review of primary spontaneous pneumothorax in the adolescent population

Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.

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.

Patient Safety During Chest Drain Insertion-A Survey of Current Practice

OBJECTIVES

The aim of this study was to identify the degree of awareness of the current guidelines and common practices for pleural drain insertion.

METHODS

A 10-item questionnaire was sent electronically to junior physicians from 4 different hospitals in the South Eastern Sydney and Illawarra Shoalhaven Local Health District. Participants were asked to give their level of experience and management practices for chest drain insertion.

RESULTS

A total of 94 junior medical officers from 4 hospitals in the district completed the survey. More than 20% had never inserted a chest drain at the time; 72% had primarily learned from bedside teaching and peer learning, but 11% had no training at all. More than 50% of physicians felt that the biggest threat to the procedure was their own lack of confidence for drain insertion. Despite current guidelines, 25% insert chest drains routinely without the aid of ultrasound. A third of interviewees were aware of local guidelines but had not read them. Most physicians (86%) believe that formal standardized training should be available for junior physicians.

CONCLUSIONS

Our findings demonstrate the ongoing need for improved procedural training in chest drain insertion, with emphasis on mandatory thoracic ultrasound. We consider it important to continue to raise concern and awareness that chest drain insertion is not a harmless procedure, and further physician procedural competence is required.

A Comparison of Prehospital Nonphysician and Hospital Physician Placed Tube Thoracostomy

BACKGROUND

Prehospital chest decompression can be a lifesaving procedure in severe chest trauma. Studies investigating prehospital chest decompression are mostly European where physicians are assigned to prehospital care units. This report is one of the first to compare demographics and outcomes in patients undergoing prehospital chest decompression by trained aeromedical nonphysician personnel to hospital chest decompression by physicians.

METHODS

Prehospital tube thoracostomy (PTT) patients were identified from January 2014 to January 2019 and were matched in a 1:2 ratio based on age, Injury Severity Score (ISS), and chest Abbreviated Injury Score (AIS) to patients who underwent hospital tube thoracostomy (HTT) within 24 hours of admission.

RESULTS

Forty-nine PTT patients were matched to 98 HTT patients. PTT patients had lower admission Glasgow Coma Scale (GCS), a higher rate of pre-chest tube needle decompression, and higher level 1 trauma activation. PTT were placed sooner (21.9 vs 157.0 minutes, P < .001). Rates of tube malposition, organ injury, tube dislodgement, empyema, and hospital-acquired pneumonia over the course of hospital admission were not significantly different between the 2 groups. PTT patients had longer intensive care unit length of stay (LOS), but similar hospital LOS, and overall mortality.

DISCUSSION

This report demonstrates that PTT is performed sooner than hospital placed tubes. Complication rates associated with tube thoracostomy and patient outcomes were not statistically different between PTT and HTT groups.

Offshore telementored ultrasound: a quality assessment study

Background

Telementored ultrasound (US) connects experts to novices through various types of communication and network technologies with the overall aim to bridge the medical imaging gap between patients’ diagnostic needs and on-site user experience. The recurrent theme in previous research on remote telementored US is the limited access to US machines and experienced users. This study was conducted to determine whether telementored US was feasible in a remote offshore setting. The aim was to assess if an onshore US expert can guide an offshore nurse through focused US scanning protocols by connecting an US machine to existing videoconference units at the offshore hospitals and to evaluate the diagnostic quality of the images and cineloops procured.

Results

The diagnostic quality of cineloops was scored on a five-point scale. The percentage of cineloops suitable for interpretation (score 3 ≥) for the FATE and e-FAST protocols was 96.4 and 79.1. Lung sliding and seashore sign could be identified in all volunteers. The scan time for the FAST protocol (n = four scanning positions), FATE protocol (n = six scanning positions) and both lungs (n = two scanning positions) was 1 min 20 s, 4 min 15 s and 32 s, respectively.

Conclusion

A novice US user can be guided by a remote expert through focused US protocols within an acceptable time frame and with good diagnostic quality using existing communication and network systems found onboard offshore oil rigs.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

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.].

Chest wall thickness and depth to vital structures in paediatric patients - implications for prehospital needle decompression of tension pneumothorax

Background

Recommendations regarding decompression of tension pneumothorax in small children are scarce and mainly transferred from the adult literature without existing evidence for the paediatric population. This CT-based study evaluates chest wall thickness, width of the intercostal space (ICS) and risk of injury to vital structures by needle decompression in children.

Methods

Chest wall thickness, width of the intercostal space and depth to vital structures were measured and evaluated at 2nd ICS midclavicular (MCL) line and 4th ICS anterior axillary line (AAL) on both sides of the thorax using computed tomography (CT) in 139 children in three different age groups (0, 5, 10 years).

Results

Width of the intercostal space was significantly smaller at the 4th ICS compared to the 2nd ICS in all age groups on both sides of the thorax. Chest wall thickness was marginally smaller at the 4th ICS compared to the 2nd ICS in infants and significantly smaller at 4th ICS in children aged 5 years and 10 years. Depth to vital structure for correct angle of needle entry was smaller at the 4th ICS in all age groups on both sides of the thorax. Incorrect angle of needle entry however is accompanied by a higher risk of injury at 2nd ICS. Furthermore, in some children aged 0 and 5 years, the heart or the thymus gland were found directly adjacent to the thoracic wall at 2nd ICS midclavicular line.

Conclusion

Especially in small children risk of iatrogenic injury to vital structures by needle decompression is considerably high. The 4th ICS AAL offers a smaller chest wall thickness, but the width of the ICS is smaller and the risk of injury to the intercostal vessels and nerve is greater. Deviations from correct angle of entry however are accompanied by higher risk of injury to intrathoracic structures at the 2nd ICS. Furthermore, we found the heart and the thymus gland to be directly adjacent to the thoracic wall at the 2nd ICS MCL in a few children. From our point of view this puncture site can therefore not be recommended for decompression in small children. We therefore recommend 4th ICS AAL as the primary site of choice.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0623-5) contains supplementary material, which is available to authorized users.

Chest drain and thoracotomy for chest trauma

Traumas are the leading cause of death in the first four decades of life. Nevertheless, thoracic traumas only seldom require invasive procedures. In particular, chest drain placement is required in case of pleural disruption causing haemothorax, pneumothorax or haemopneumothorax. Although large-bore chest drains have been traditionally used in case of haemothorax, recent evidences seem to question this routine, showing good performances of small-bore and pig tail drains. Although it is a common procedures, experience and training is needed to avoid complications which might be even lethal. Surgical exploration after thoracic trauma is rare, accounting for less than 3% of traumas. Penetrating traumas more likely require surgical exploration compared to blunt trauma. Anterolateral thoracotomy is usually performed in this setting, but also clamshell or hemi-clamshell approach can be used. In selected patients, minimally invasive techniques can be performed. Large randomized trials are still needed to assess and standardized the role of new tools and procedures in the thoracic trauma setting.

Point-of-Care Diagnostic Device for Traumatic Pneumothorax: Low Sensitivity of the Unblinded PneumoScan™

BACKGROUND

Traumatic Pneumothorax (PTX) is a potentially life-threatening injury. It requires a fast and accurate diagnosis and treatment, but diagnostic tools are limited. A new point-of-care device (PneumoScan) based on micropower impulse radar (MIR) promises to diagnose a PTX within seconds. In this study, we compare standard diagnostics with PneumoScan during shock-trauma-room management.

PATIENTS AND METHODS

Patients with blunt or penetrating chest trauma were consecutively included in the study. All patients were examined including clinical examination with auscultation (CE) and supine chest radiography (CXR). In addition, PneumoScan-readings and thoracic ultrasound scan (US) were performed. Computed tomography (CT) served as gold standard.

RESULTS

CT scan revealed PTX in 11 patients. PneumoScan detected two PTX correctly but missed nine. 15 false-positive results were found by PneumoScan, leading to a sensitivity of 20% and specificity of 80%. Six PTX were detected through CE (sensitivity: 54,5%). CXR detected four (sensitivity: 27,3%) and thoracic US two PTX correctly (sensitivity: 25%).

CONCLUSION

The unblinded PneumoScan prototype did not confirm the promising results of previous studies. The examined standard diagnostics and thoracic US showed rather weak sensitivity as well. Until now, there is no appropriate point-of-care tool to rule out PTX.

Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP)

Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the ‘safe zone’ of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation.

Management of chest trauma

Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.

Chest trauma: First 48hours management

Chest trauma remains an issue for health services for both severe and apparently mild trauma management. Severe chest trauma is associated with high mortality and is considered liable for 25% of mortality in multiple traumas. Moreover, mild trauma is also associated with significant morbidity especially in patients with preexisting conditions. Thus, whatever the severity, a fast-acting strategy must be organized. At this time, there are no guidelines available from scientific societies. These expert recommendations aim to establish guidelines for chest trauma management in both prehospital an in hospital settings, for the first 48hours. The "Société française d'anesthésie réanimation" and the "Société française de médecine d'urgence" worked together on the 7 following questions: (1) criteria defining severity and for appropriate hospital referral; (2) diagnosis strategy in both pre- and in-hospital settings; (3) indications and guidelines for ventilatory support; (4) management of analgesia; (5) indications and guidelines for chest tube placement; (6) surgical and endovascular repair indications in blunt chest trauma; (7) definition, medical and surgical specificity of penetrating chest trauma. For each question, prespecified "crucial" (and sometimes also "important") outcomes were identified by the panel of experts because it mattered for patients. We rated evidence across studies for these specific clinical outcomes. After a systematic Grade^® approach, we defined 60 recommendations. Each recommendation has been evaluated by all the experts according to the DELPHI method.

The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh

‘The pre-hospital management of chest injury: a consensus statement’ was originally published by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in 2007. To update the pre-existing guideline, a consensus meeting of stakeholders was held by the Faculty of Pre-hospital Care in Coventry in November 2013. This paper provides a guideline for the pre-hospital management of patients with the life-threatening chest injuries of tension pneumothorax, open pneumothorax, massive haemothorax, flail chest (including multiple rib fractures), and cardiac tamponade.

Safety and Efficacy of Thoracostomy in the Air Medical Environment

OBJECTIVE

The use of thoracostomy to treat tension pneumothorax is a core skill for prehospital providers. Tension pneumothoraces are potentially lethal and are often encountered in the prehospital environment.

METHODS

The authors reviewed the prehospital electronic medical records of patients who had undergone finger thoracostomy (FT) or tube thoracostomy (TT) while under the care of air medical crewmembers. Demographic data were obtained along with survival and complications.

RESULTS

During the 90-month data period, 250 patients (18 years of age or older) underwent FT/TT, with a total of 421 procedures performed. The mean age of patients was 44.8 years, with 78.4% being male and 21.6% being female; 98.4% of patients had traumatic injuries. Cardiopulmonary resuscitation was required in 65.2% of patients undergoing FT/TT; 34.8% did not require cardiopulmonary resuscitation. Thirty percent of patients exhibited clinical improvement such as increasing systolic blood pressure, oxygen saturation, improved lung compliance, or a release of blood or air under tension. Patients who experienced complications such as tube dislodgement or empyema made up 3.4% of the cohort.

CONCLUSION

The results of this study suggest that flight crews can use FT/TT in their practice on patients with actual or potential pneumothoraces with limited complications and generate clinical improvement in a subset of patients.

Air transport of patients with pneumothorax: is tube thoracostomy required before flight?

OBJECTIVE

It is conventionally thought that patients with pneumothorax (PTX) require tube thoracostomy (TT) before air medical transport (AMT), especially in unpressurized rotor-wing (RW) aircraft, to prevent deterioration from expansion of the PTX or development of tension PTX. We hypothesize that patients with PTX transported without TT tolerate RW AMT without serious deterioration, as defined by hypotension, hypoxemia, respiratory distress, intubation, bag valve mask ventilation, needle thoracostomy (NT), or cardiac arrest during transport.

METHODS

We conducted a retrospective review of a case-series of trauma patients transported to a single Level 1 trauma center via RW with confirmed PTX and no TT. Using standardized abstraction forms, we reviewed charts for signs of deterioration. Those patients identified as having clinical deterioration were independently reviewed for the likelihood that the clinical deterioration was a direct consequence of PTX.

RESULTS

During the study period, 66 patients with confirmed PTX underwent RW AMT with an average altitude gain of 1890 feet, an average barometric pressure 586-600 mmHg, and average flight duration of 28 minutes. All patients received oxygen therapy; 14/66 patients (21%) were supported with positive pressure ventilation. Eleven of 66 patients (17%) had NT placed before flight and 4/66 (6%) had NT placed during flight. Four of 66 patients (6% CI0.3-11.7) may have deteriorated during AMT as a result of PTX; all were successfully managed with NT.

CONCLUSIONS

In this series, 6% of patients with PTX deteriorated as result of AMT without TT, yet all patients were managed successfully with NT. Routine placement of TT in patients with PTX before RW AMT may not be necessary. Further prospective evaluation is warranted.

Complications of needle thoracostomy: A comprehensive clinical review

Needle thoracostomy (NT) is a valuable adjunct in the management of tension pneumothorax (tPTX), a life-threatening condition encountered mainly in trauma and critical care environments. Most commonly, needle thoracostomies are used in the prehospital setting and during acute trauma resuscitation to temporize the affected individuals prior to the placement of definitive tube thoracostomy (TT). Because it is both an invasive and emergent maneuver, NT can be associated with a number of potential complications, some of which may be life-threatening. Due to relatively common use of this procedure, it is important that healthcare providers are familiar, and ready to deal with, potential complications of NT.

Failed needle decompression of bilateral spontaneous tension pneumothorax

This case report presents a young male admitted with primary bilateral spontaneous tension pneumothorax and severe respiratory distress. This is an extremely rare condition. The patient was on the verge of hypoxic cardiac arrest and the attempted needle thoracocentesis was unsuccessful. Needle thoracocentesis in the midclavicular line of the second intercostal space is widely used and recommended as first-line treatment of tension pneumothorax. Reviewing the literature, the procedure is not based on solid evidence. It has high failure rates and potentially serious complications. Alternatives to this approach are perhaps more appropriate. Correctly done, needle thoracocentesis has its place in the presence of a diagnosed or suspected tension pneumothorax when no other options are available. If needle thoracocentesis is chosen, then insertion in the mid-anterior axillary line of the 3rd-5th intercostal space is an appropriate alternative site. Otherwise, lateral thoracostomy, with or without chest tube insertion, is a safe procedure with a high success rate. It should be considered as the first-line treatment of tension pneumothorax, particularly in the unstable patient.

Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax

BACKGROUND

Five-centimeter needles at the second intercostal space midclavicular line (2MCL) have high failure rates for decompression of tension pneumothorax. This study evaluates 8-cm needles directed at the fourth intercostal space anterior axillary line (4AAL).

METHODS

Retrospective radiographic analysis of 100 consecutive trauma patients 18 years or older from January to September 2011. Measurements of chest wall thickness (CWT) and depth to vital structure (DVS) were obtained at 2MCL and 4AAL. 4AAL measurements were taken based on two angles: closest vital structure and perpendicular to the chest wall. Primary outcome measures were radiographic decompression (RD) (defined as CWT < 80 mm) and radiographic noninjury (RNI) (DVS > 80 mm) of 8-cm needles at 4AAL. Secondary outcome measures are effect of angle of entry on RNI at 4AAL, RD and RNI of 8-cm needles at 2MCL, and comparison of 5-cm needles with 8-cm needles at both locations.

RESULTS

Eighty-four percent of the patients were male, with mean Injury Severity Score (ISS) of 17.7 (range, 1.0-66.0) and body mass index of 26.8 (16.5-48.4). Mean CWT at 4AAL ranged from 37.6 mm to 39.9 mm, significantly thinner than mean CWT at 2MCL (43.3-46.7 mm). Eight-centimeter needle RD was more than 96% at both 4AAL and 2MCL. Five-centimeter RD ranged from 66% to 81% at all sites. Mean DVS at 4AAL ranged from 91.8 mm to 128.0 mm. RNI at all sites was more than 91% except at left 4AAL, when taken to the closest vital structure (mean DVS, 91.8 mm), with 68% RNI. Perpendicular entry increased DVS to 109.4 mm and subsequent RNI to 91%. Five-centimeter RNI at all sites was more than 99%.

CONCLUSION

CWT at 4AAL is significantly thinner than 2MCL. Based on radiographic measurements, 8-cm catheters have a higher chance of pleural decompression when compared with 5-cm catheters. Steeper angle of entry at 4AAL improves 8-cm noninjury rates to more than 91%.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis

BACKGROUND

Although health care providers utilize classically described signs and symptoms to diagnose tension pneumothorax, available literature sources differ in their descriptions of its clinical manifestations. Moreover, while the clinical manifestations of tension pneumothorax have been suggested to differ among subjects of varying respiratory status, it remains unknown if these differences are supported by clinical evidence. Thus, the primary objective of this study is to systematically describe and contrast the clinical manifestations of tension pneumothorax among patients receiving positive pressure ventilation versus those who are breathing unassisted.

METHODS/DESIGN

We will search electronic bibliographic databases (MEDLINE, PubMed, EMBASE, and the Cochrane Database of Systematic Reviews) and clinical trial registries from their first available date as well as personal files, identified review articles, and included article bibliographies. Two investigators will independently screen identified article titles and abstracts and select observational (cohort, case-control, and cross-sectional) studies and case reports and series that report original data on clinical manifestations of tension pneumothorax. These investigators will also independently assess risk of bias and extract data. Identified data on the clinical manifestations of tension pneumothorax will be stratified according to whether adult or pediatric study patients were receiving positive pressure ventilation or were breathing unassisted, as well as whether the two investigators independently agreed that the clinical condition of the study patient(s) aligned with a previously published tension pneumothorax working definition. These data will then be summarized using a formal narrative synthesis alongside a meta-analysis of observational studies and then case reports and series where possible. Pooled or combined estimates of the occurrence rate of clinical manifestations will be calculated using random effects models (for observational studies) and generalized estimating equations adjusted for reported potential confounding factors (for case reports and series).

DISCUSSION

This study will compile the world literature on tension pneumothorax and provide the first systematic description of the clinical manifestations of the disorder according to presenting patient respiratory status. It will also demonstrate a series of methods that may be used to address difficulties likely to be encountered during the conduct of a meta-analysis of data contained in published case reports and series. PROSPERO registration number: CRD42013005826.

Does Radar Technology Support the Diagnosis of Pneumothorax? PneumoScan-A Diagnostic Point-of-Care Tool

Background. A nonrecognized pneumothorax (PTX) may become a life-threatening tension PTX. A reliable point-of-care diagnostic tool could help in reduce this risk. For this purpose, we investigated the feasibility of the use of the PneumoScan, an innovative device based on micropower impulse radar (MIR). Patients and Methods. addition to a standard diagnostic protocol including clinical examination, chest X-ray (CXR), and computed tomography (CT), 24 consecutive patients with chest trauma underwent PneumoScan testing in the shock trauma room to exclude a PTX. Results. The application of the PneumoScan was simple, quick, and reliable without functional disorder. Clinical examination and CXR each revealed one and PneumoScan three out of altogether four PTXs (sensitivity 75%, specificity 100%, positive predictive value 100%, and negative predictive value 95%). The undetected PTX did not require intervention. Conclusion. The PneumoScan as a point-of-care device offers additional diagnostic value in patient management following chest trauma. Further studies with more patients have to be performed to evaluate the diagnostic accuracy of the device.

Using thoracic ultrasonography to accurately assess pneumothorax progression during positive pressure ventilation: a comparison with CT scanning

BACKGROUND

Although thoracic ultrasonography accurately determines the size and extent of occult pneumothoraces (PTXs) in spontaneously breathing patients, there is uncertainty about patients receiving positive pressure ventilation. We compared the lung point (ie, the area where the collapsed lung still adheres to the inside of the chest wall) using the two modalities ultrasonography and CT scanning to determine whether ultrasonography can be used reliably to assess PTX progression in a positive-pressure-ventilated porcine model.

METHODS

Air was introduced in incremental steps into fi ve hemithoraces in three intubated porcine models. The lung point was identified on ultrasound imaging and referenced against the lateral limit of the intrapleural air space identified on the CT scans. The distance from the sternum to the lung point (S-LP) was measured on the CT scans and correlated to the insufflated air volume.

RESULTS

The mean total difference between the 131 ultrasound and CT scan lung points was 6.8 mm (SD, 7.1 mm; range, 0.0-29.3 mm). A mixed-model regression analysis showed a linear relationship between the S-LP distances and the PTX volume ( P , .001).

CONCLUSIONS

In an experimental porcine model, we found a linear relation between the PTX size and the lateral position of the lung point. The accuracy of thoracic ultrasonography for identifying the lung point (and, thus, the PTX extent) was comparable to that of CT imaging. These clinically relevant results suggest that ultrasonography may be safe and accurate in monitoring PTX progression during positive pressure ventilation.

The intrapleural volume threshold for ultrasound detection of pneumothoraces: an experimental study on porcine models

Background

Small pneumothoraxes (PTXs) may not impart an immediate threat to trauma patients after chest injuries. However, the amount of pleural air may increase and become a concern for patients who require positive pressure ventilation or air ambulance transport. Lung ultrasonography (US) is a reliable tool in finding intrapleural air, but the performance characteristics regarding the detection of small PTXs need to be defined. The study aimed to define the volume threshold of intrapleural air when PTXs are accurately diagnosed with US and compare this volume with that for chest x-ray (CXR).

Methods

Air was insufflated into a unilateral pleural catheter in seven incremental steps (10, 25, 50, 100, 200, 350 and 500 mL) in 20 intubated porcine models, followed by a diagnostic evaluation with US and a supine anteroposterior CXR. The sonographers continued the US scanning until the PTXs could be ruled in, based on the pathognomonic US “lung point” sign. The corresponding threshold volume was noted. A senior radiologist interpreted the CXR images.

Results

The mean threshold volume to confirm the diagnosis of PTX using US was 18 mL (standard deviation of 13 mL). Sixty-five percent of the PTXs were already diagnosed at 10 mL of intrapleural air; 25%, at 25 mL; and the last 10%, at 50 mL. At an air volume of 50 mL, the radiologist only identified four out of 20 PTXs in the CXR pictures; i.e., a sensitivity of 20% (95% CI: 7%, 44%). The sensitivity of CXR increased as a function of volume but leveled off at 67%, leaving one-third (1/3) of the PTXs unidentified after 500 mL of insufflated air.

Conclusion

Lung US is very accurate in diagnosing even small amounts of intrapleural air and should be performed by clinicians treating chest trauma patients when PTX is among the differential diagnoses.

Evolved design makes ThoraQuik safe and user friendly in the management of pneumothorax and pleural effusion

Background

We have previously described the utility of ThoraQuik, a device designed to be fit for purpose for aspirations of pneumothorax and pleural effusions. We evaluated the safety, efficacy and operator handling of the evolved prototype, ThoraQuik II, which has a lesser profile and a spring loaded Veres needle for added safety.

Methods

A prospective, observational clinical trial with ethics and MHRA approval was conducted in a single centre. Patients with diagnosed pneumothorax (including tension pneumothorax) and pleural effusion were consented and recruited. The ease of device introduction, penetration and ease of use were evaluated. Clinical and radiological improvements were the clinical endpoints and operator feedback was analysed.

Results

20 procedures were performed on patients (mean age: 63.4 years (range: 30–90 years) with 75% male subjects) recruited between September 2008 and August 2009. Nine patients had pneumothorax (tension pneumothorax n=4) and 11 had pleural effusions. 19 patients completed the study with symptomatic and radiological resolution. One patient was withdrawn due to poor pain threshold disproportionate to the procedure. No complications were encountered. 68% had complete clinical and radiological resolution and 32% had partial resolution (these patients needed a definitive drain and hence were not aspirated to completion). The operator feedback in the study rated the device as very good or excellent in 90% patients.

Conclusions

Our study found the use of ThoraQuik II to be safe and easy in draining pneumothorax and pleural effusions. The changes to ThoraQuik II made it more user friendly.

[Preclinical management of multiples injuries: S3 guideline]

The guidelines follow the priorities established by the A-B-C-D-E scheme. They focus on the treatment of actual disturbances of vital functions and not so much on their anticipated development. Important recommendations with regard to the indication for intubation and ventilation, fluid therapy, diagnosis and treatment of severe chest injuries (tension pneumothorax in particular), management of severe traumatic brain injury, pelvic and vertebral injuries, priorities in the management of extremity fractures as well as indications for the choice of the receiving hospital are given. The recommendations are discussed in view of future concerns and developments.

Evaluation of performance of two different chest tubes with either a sharp or a blunt tip for thoracostomy in 100 human cadavers

BACKGROUND

Emergent placement of a chest tube is a potentially life-saving procedure, but rate of misplacement and organ injury is up to 30%. In principle, chest tube insertion can be performed by using Trocar or Non-trocar techniques. If using trocar technique, two different chest tubes (equipped with sharp or blunt tip) are currently commercially available. This study was performed to detect any difference with respect to time until tube insertion, to success and to misplacement rate.

METHODS

Twenty emergency physicians performed five tube thoracostomies using both blunt and sharp tipped tube kits in 100 fresh human cadavers (100 thoracostomies with each kit). Time until tube insertion served as primary outcome. Complications and success rate were examined by pathological dissection and served as further outcomes parameters.

RESULTS

Difference in mean time until tube insertion (63 s vs. 59 s) was statistically not significant. In both groups, time for insertion decreased from the 1st to the 5th attempt and showed dependency on the cadaver's BMI and on the individual physician. Success rate differed between both groups (92% using blunt vs. 86% using sharp tipped kits) and injuries and misplacements occurred significantly more frequently using chest tubes with sharp tips (p = 0.04).

CONCLUSION

Data suggest that chest drain insertion with trocars is associated with a 6-14% operator-related complication rate. No difference in average time could be found. However, misplacements and organ injuries occurred more frequently using sharp tips. Consequently, if using a trocar technique, the use of blunt tipped kits is recommended.

Paramedics' and pre-hospital physicians' assessments of anatomic injury in trauma patients: a cohort study

BACKGROUND

The pre-hospital assessment of a blunt trauma is difficult. Common triage tools are the mechanism of injury (MOI), vital signs, and anatomic injury (AI). Compared to the other tools, the clinical assessment of anatomic injury is more subjective than the others, and, hence, more dependent on the skills of the personnel.The aim of the study was to estimate whether the training and qualifications of the personnel are associated with the accuracy of prediction of anatomic injury and the completion of pre-hospital procedures indicated by local guidelines.

METHODS

Adult trauma patients met by a trauma team at Helsinki University Trauma Centre during a 12-month period (n = 422) were retrospectively analysed. To evaluate the accuracy of prediction of anatomic injury, clinically assessed pre-hospital injuries in six body regions were compared to injuries assessed at hospital in two patient groups, the patients treated by pre-hospital physicians (group 1, n = 230) and those treated by paramedics (group 2, n = 190).

RESULTS

The groups were comparable in respect to age, sex, and MOI, but the patients treated by physicians were more severely injured than those treated by paramedics [ISS median (interquartile range) 16 (6-26) vs. 6 (2-10)], thus rendering direct comparison of the groups ineligible. The positive predictive values (95% confidence interval) of assessed injury were highest in head injury [0,91 (0,84-0,95) in group 1 and 0,86 (0,77-0,92) in group 2]. The negative predictive values were highest in abdominal injury [0,85 (0,79-0,89) in group 1 and 0,90 (0,84-0,93) in group 2]. The measurements of agreement between injuries assessed pre- and in-hospitally were moderate in thoracic and extremity injuries. Substantial kappa values (95% confidence interval) were achieved in head injury, 0,67 (0,57-0,77) in group 1 and 0,63 (0,52-0,74) in group 2. The rate of performing the pre-hospital procedures as indicated by the local instructions was 95-99%, except for decompression of tension pneumothorax.

CONCLUSION

Accurate prediction of anatomic injury is challenging. No conclusive differences were seen in the ability of pre-hospital physicians and paramedics to predict anatomic injury in the respective patient populations.

Malfunction of a Heimlich flutter valve causing tension pneumothorax: case report of a rare complication

BACKGROUND

Thoracic injuries play an important role in major trauma patients due to their high incidence and critical relevance. A serious consequence of thoracic trauma is pneumothorax, a condition that quickly can become life-threatening and requires immediate treatment.Decompression is the state of the art for treating tension pneumothorax. There are many different methods of decompression using different techniques, devices, valves and drainage systems. Referring to our case report we would like to discuss the utilization of these devices.

CASE PRESENTATION

We report of a patient suffering from tension pneumothorax despite insertion of a chest drain at the accident scene. The decompression was by tube thoracostomy which was connected to a Heimlich flutter valve. During air transportation the patient suffered from cardiorespiratory arrest with asystole and was admitted to the trauma room undergoing manual chest compressions. The initial chest film showed a persisting tension pneumothorax, despite the chest tube that had been correctly placed and connected properly to the Heimlich valve. We assume that the Heimlich valve leaves did not open up and thus tension pneumothorax was not released.

CONCLUSION

We would like to raise awareness to the fact that if a Heimlich flutter valve is applied in the pre-hospital setting it should be used with caution. Failure in this type of valve may lead to recurrent tension pneumothorax.