1
|
Lenn D, Le DT, Scheiber CJ, Smeltz AM. The Perfect Med Bag is One that Doesn't Fall Off a Cliff: A Combat Mass Casualty Case. Mil Med 2024; 189:e2268-e2273. [PMID: 37975228 DOI: 10.1093/milmed/usad444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/19/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- David Lenn
- SCPO (USN), 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, NC 28547, USA
| | - Daniel T Le
- ENS (USNR), University of North Carolina School of Medicine, Bondurant Hall, CB #9500, Chapel Hill, NC 27599, USA
| | - Christopher J Scheiber
- Department of Anesthesiology, N2198, CB7010, The University of North Carolina at Chapel Hill, UNC Hospitals, Chapel Hill, NC 27599-7010, USA
| | - Alan M Smeltz
- Cardiothoracic Division, Department of Anesthesiology, N2198, CB7010, The University of North Carolina at Chapel Hill, UNC Hospitals, Chapel Hill, NC 27599-7010, USA
| |
Collapse
|
2
|
Waydhas C, Prediger B, Kamp O, Kleber C, Nohl A, Schulz-Drost S, Schreyer C, Schwab R, Struck MF, Breuing J, Trentzsch H. Prehospital management of chest injuries in severely injured patients-a systematic review and clinical practice guideline update. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02457-3. [PMID: 38308661 DOI: 10.1007/s00068-024-02457-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/22/2024] [Indexed: 02/05/2024]
Abstract
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.
Collapse
Affiliation(s)
- Christian Waydhas
- Department of Trauma, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany.
- Department of Surgery, BG Bergmannsheil University Hospital, Bochum, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Oliver Kamp
- Department of Trauma, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany
| | - Christian Kleber
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, Leipzig University Hospital, Leipzig, Germany
| | - André Nohl
- Centre of Emergency Medicine, BG Duisburg Hospital, Duisburg, Germany
| | - Stefan Schulz-Drost
- Zentrum für Bewegungs- und Altersmedizin, Helios Kliniken Schwerin, Schwerin, Germany
- Department für Unfall- und Orthopädische Chirurgie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christof Schreyer
- Department of General, Visceral and Thoracic Surgery, Bundeswehr Central Hospital, Koblenz, Germany
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, Bundeswehr Central Hospital, Koblenz, Germany
| | - Manuel Florian Struck
- Department of Anaesthesiology and Intensive Care Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Jessica Breuing
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Heiko Trentzsch
- Institute of Emergency Medicine and Medical Management, LMU Munich University Hospital, Munich, Germany
| |
Collapse
|
3
|
Advanced and Invasive Cardiopulmonary Resuscitation (CPR) Techniques as an Adjunct to Advanced Cardiac Life Support. J Clin Med 2022; 11:jcm11247315. [PMID: 36555932 PMCID: PMC9781548 DOI: 10.3390/jcm11247315] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite numerous promising innovations, the chance of survival from sudden cardiac arrest has remained virtually unchanged for decades. Recently, technological advances have been made, user-friendly portable devices have been developed, and advanced invasive procedures have been described that could improve this unsatisfactory situation. METHODS A selective literature search in the core databases with a focus on randomized controlled trials and guidelines. RESULTS Technical aids, such as feedback systems or automated mechanical cardiopulmonary resuscitation (CPR) devices, can improve chest compression quality. The latter, as well as extracorporeal CPR, might serve as a bridge to treatment (with extracorporeal CPR even as a bridge to recovery). Sonography may be used to improve thoracic compressions on the one hand and to rule out potentially reversible causes of cardiac arrest on the other. Resuscitative endovascular balloon occlusion of the aorta might enhance myocardial and cerebral perfusion. Minithoracostomy, pericardiocentesis, or clamshell thoracotomy might resolve reversible causes of cardiac arrest. CONCLUSIONS It is crucial to identify those patients who may benefit from an advanced or invasive procedure and make the decision to implement the intervention in a timely manner. As with all infrequently performed procedures, sound education and regular training are paramount.
Collapse
|
4
|
Merelman A, Zink N, Fisher AD, Lauria M, Braude D. FINGER: A Novel Approach to Teaching Simple Thoracostomy. Air Med J 2022; 41:526-529. [PMID: 36494167 DOI: 10.1016/j.amj.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 12/14/2022]
Abstract
For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax.
Collapse
Affiliation(s)
- Andrew Merelman
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
| | | | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM; Texas Army National Guard, Austin, TX
| | - Michael Lauria
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Lifeguard Emergency and Critical Care Transport, Albuquerque, NM
| | - Darren Braude
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Lifeguard Emergency and Critical Care Transport, Albuquerque, NM
| |
Collapse
|
5
|
Holland HK, Holena DN. Moving the Needle on Early Mortality After Injury-A Role for Liberalizing Prehospital Needle Decompression? JAMA Surg 2022; 157:941. [PMID: 35976665 DOI: 10.1001/jamasurg.2022.3561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Daniel N Holena
- Department of Surgery, Medical College of Wisconsin, Wauwatosa
| |
Collapse
|
6
|
Lubin JS, Knapp J, Kettenmann ML. Paramedic Understanding of Tension Pneumothorax and Needle Thoracostomy (NT) Site Selection. Cureus 2022; 14:e27013. [PMID: 35989820 PMCID: PMC9386319 DOI: 10.7759/cureus.27013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Tension pneumothorax is an immediate threat to life. Treatment in the prehospital setting is usually achieved by needle thoracostomy (NT). Prehospital personnel are taught to perform NT, frequently in the second intercostal space (ICS) at the mid-clavicular line (MCL). Previous literature has suggested that emergency physicians have difficulty identifying this anatomic location correctly. We hypothesized that paramedics would also have difficulty accurately identifying the proper location for NT. Methods A prospective, observational study was performed to assess paramedic ability to identify the location for treatment with NT. Participants were recruited during a statewide Emergency Medical Services (EMS) conference. Subjects were asked the anatomic site for NT and asked to mark the site on a shirtless male volunteer. The site was copied onto a transparent sheet lined up against predetermined points on the volunteer’s chest. It was then compared against the correct location that had been identified using palpation, measuring tape, and ultrasound. Results 29 paramedics participated, with 24 (83%) in practice for more than five years and 23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) reported training in NT, although six (21%) had never performed a NT in the field. Nine paramedics (31%) recognized the second ICS at the MCL as the desired site for NT, with 12 (41%) specifying only the second ICS, 11 (38%) specifying second or third ICS, and six (21%) naming a different location (third, fourth, or fifth ICS). None (0%) of the 29 paramedics identified the exact second ICS MCL on the volunteer. Mean distance from the second ICS MCL was 1.37 cm (interquartile range (IQR): 0.7-1.90) in the medial-lateral direction and 2.43 cm in the superior-inferior direction (IQR: 1.10-3.70). Overall mean distance was 3.12 cm from the correct location (IQR: 1.90-4.50). Most commonly, the identified location was too inferior (93%). Allowing for a 2 cm radius from the correct position, eight (28%) approximated the correct placement. 25 (86%) were within a 5 cm radius. Conclusion In this study, paramedics had difficulty identifying the correct anatomic site for NT. EMS medical directors may need to rethink training or consider alternative techniques.
Collapse
|
7
|
To Watch Before or Listen While Doing? A Randomized Pilot of Video-Modelling versus Telementored Tube Thoracostomy. Prehosp Disaster Med 2022; 37:71-77. [PMID: 35177133 DOI: 10.1017/s1049023x22000097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
Collapse
|
8
|
Harris CT, Taghavi S, Bird E, Duchesne J, Jacome T, Tatum D. Prehospital Simple Thoracostomy Does Not Improve Patient Outcomes Compared to Needle Thoracostomy in Severely Injured Trauma Patients. Am Surg 2022:31348221075746. [PMID: 35142224 DOI: 10.1177/00031348221075746] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Charles T Harris
- Section of Trauma and Critical Care, Department of Surgery, 12256Tulane University, New Orleans, LA, USA
| | - Sharven Taghavi
- Section of Trauma and Critical Care, Department of Surgery, 12256Tulane University, New Orleans, LA, USA
| | - Emily Bird
- Trauma Services, 23087Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | - Juan Duchesne
- Section of Trauma and Critical Care, Department of Surgery, 12256Tulane University, New Orleans, LA, USA
| | - Tomas Jacome
- Trauma Services, 23087Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | - Danielle Tatum
- Section of Trauma and Critical Care, Department of Surgery, 12256Tulane University, New Orleans, LA, USA
| |
Collapse
|
9
|
Newton G, Laing CM, Reay G, King-Shier K. Thoracic Endotracheal Tube Insertion During Prehospital Thoracostomy: A Case Report. Air Med J 2021; 40:182-184. [PMID: 33933223 DOI: 10.1016/j.amj.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Graham Newton
- Shock Trauma Air Rescue Service, Calgary, Alberta, Canada.
| | | | - Gudrun Reay
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
10
|
Newton G, Reay G, Laing CM, King-Shier K. Clinical Characteristics of Patients Undergoing Needle Thoracostomy in a Canadian Helicopter Emergency Medical Service. PREHOSP EMERG CARE 2021; 26:400-405. [PMID: 33818257 DOI: 10.1080/10903127.2021.1912226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- Graham Newton
- Shock Trauma Air Rescue Service, Calgary, AB, Canada
| | - Gudrun Reay
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | | | | |
Collapse
|
11
|
Lee CC, Chuang CC, Lu CL, Lai BC, So EC, Lin BS. A novel optical technology based on 690 nm and 850 nm wavelengths to assist needle thoracostomy. Sci Rep 2021; 11:3874. [PMID: 33594120 PMCID: PMC7887237 DOI: 10.1038/s41598-021-81225-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/04/2021] [Indexed: 11/09/2022] Open
Abstract
The sensitivity of pneumothorax diagnosis via handheld ultrasound is low, and there is no equipment suitable for use with life-threatening tension pneumothorax in a prehospital setting. This study proposes a novel technology involving optical fibers and near-infrared spectroscopy to assist in needle thoracostomy decompression. The proposed system via the optical fibers emitted dual wavelengths of 690 and 850 nm, allowing distinction among different layers of tissue in vivo. The fundamental principle is the modified Beer-Lambert law (MBLL) which is the basis of near-infrared tissue spectroscopy. Changes in optical density corresponding to different wavelengths (690 and 850 nm) and hemoglobin parameters (levels of Hb and HbO2) were examined. The Kruskal-Wallis H test was used to compare the differences in parameter estimates among tissue layers; all p-values were < 0.001 relevant to 690 nm and 850 nm. In comparisons of Hb and HbO2 levels relative to those observed in the vein and artery, all p-values were also < 0.001. This study proposes a new optical probe to assist needle thoracostomy in a swine model. Different types of tissue can be identified by changes in optical density and hemoglobin parameters. The aid of the proposed system may yield fewer complications and a higher success rate in needle thoracostomy procedures.
Collapse
Affiliation(s)
- Chien-Ching Lee
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, Taiwan.,Department of Anesthesiology, An Nan Hospital, China Medical University, Tainan, Taiwan.,Department of Medical Sciences Industry, Chang Jung Christian University, Tainan, Taiwan
| | - Chia-Chun Chuang
- Department of Anesthesiology, An Nan Hospital, China Medical University, Tainan, Taiwan.,Department of Medical Sciences Industry, Chang Jung Christian University, Tainan, Taiwan
| | - Chin-Li Lu
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung Hsing University, Taichung, Taiwan
| | - Bo-Cheng Lai
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, Taiwan
| | - Edmund Cheung So
- Department of Anesthesiology, An Nan Hospital, China Medical University, Tainan, Taiwan.,Department of Medical Sciences Industry, Chang Jung Christian University, Tainan, Taiwan
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, Taiwan.
| |
Collapse
|
12
|
Butler WJ, Smith JE, Tadlock MD, Martin MJ. Initial Assessment and Resuscitation of the Battlefield Casualty—an Overview. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00200-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
13
|
Gemal H, Lu TC, Peeceeyen S. Delayed massive haemopneumothorax with shock after 'Zumba'. ANZ J Surg 2020; 91:E212-E213. [PMID: 32845555 DOI: 10.1111/ans.16283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/26/2020] [Accepted: 08/15/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Hugo Gemal
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, New South Wales, Australia.,Emergency Department, St George Hospital, Sydney, New South Wales, Australia
| | - Thomas Chengxuan Lu
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, New South Wales, Australia.,Emergency Department, St George Hospital, Sydney, New South Wales, Australia.,The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Sheen Peeceeyen
- Department of Cardiothoracic Surgery, St George Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Comparison of 10- versus 14-gauge angiocatheter for treatment of tension pneumothorax and tension-induced pulseless electrical activity with hemorrhagic shock: Bigger is still better. J Trauma Acute Care Surg 2020; 89:S132-S136. [PMID: 32366761 DOI: 10.1097/ta.0000000000002724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known regarding the effect of hemorrhagic shock on the diagnosis and treatment of tension pneumothorax (tPTX). Recently, the Tactical Combat Casualty Care guidelines included the 10-gauge angiocatheter (10-g AC) as an acceptable alternative to the 14-g AC. This study sought to compare these two devices for decompression of tPTX and rescue from tension-induced pulseless electric activity (tPEA) in the setting of a concomitant 30% estimated blood volume hemorrhage. METHODS Following a controlled hemorrhage, carbon dioxide was insufflated into the chest to induce either tPTX or tPEA. Tension pneumothorax was defined as a reduction in cardiac output by 50%, and tPEA was defined as a loss of arterial waveform with mean arterial pressure less than 20 mm Hg. The affected hemithorax was decompressed using a randomized 14-g AC or 10-g AC while a persistent air leak was maintained after decompression. Successful rescue from tPTX was defined as 80% recovery of baseline systolic blood pressure, while successful return of spontaneous circulation following tPEA was defined as a mean arterial pressure greater than 20 mm Hg. Primary outcome was success of device. RESULTS Eighty tPTX and 50 tPEA events were conducted in 38 adult Yorkshire swine. There were no significant differences in the baseline characteristics between animals or devices. In the tPTX model, the 10-g AC successfully rescued 90% of events, while 14-g AC rescued 80% of events (p = 0.350). In the tPEA model, the 10-g AC rescued 87% of events while the 14 AC rescued only 48% of events (p = 0.006). CONCLUSION The 10-g AC was vastly superior to the 14-g AC for return of spontaneous circulation following tPEA in the setting of 30% hemorrhage. These findings further support the importance of larger caliber devices that facilitate rapid recovery from tPTX, particularly in the setting of polytrauma. LEVEL OF EVIDENCE Therapeutic, level II.
Collapse
|
16
|
Rowland D, Vryhof N, Overton D, Mastenbrook J. Tension Hemopneumothorax in the Setting of Mechanical CPR during Prehospital Cardiac Arrest. PREHOSP EMERG CARE 2020; 25:274-280. [PMID: 32208039 DOI: 10.1080/10903127.2020.1743800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION There are several complications associated with automated mechanical CPR (AM-CPR), including tension pneumothoraces. The incidence of these complications and the risk factors for their development remain poorly characterized. Tension hemopneumothorax is a previously unreported complication of AM-CPR. The authors present a case of a suspected tension hemopneumothorax that developed during the use of an automated mechanical CPR device. Case Description: A 67 year-old woman with a history of COPD and CABG was observed by an off-duty firefighter to be slumped behind the wheel of an ice cream truck that drifted off the road at a low rate of speed and was stopped by a wooden fence, resulting in only minor paint scratches. The patient was found to be in cardiac arrest with a shockable rhythm. No signs of trauma were noted, and equal bilateral breath sounds were present with BVM ventilation. After 13 minutes of manual CPR, fire department personnel applied their Defibtech LifeLine ARM mechanical CPR device to the patient. During resuscitation, the device had to be repositioned twice due to rightward piston migration off of the sternum. Seven minutes after AM-CPR application, the patient had absent right-sided breath sounds and ventilations were more difficult. Needle decompression was performed with an audible release of air. A chest tube was placed by an EMS physician and roughly 400 mL of blood were immediately returned. At the next 2-minute pulse check, ROSC was noted, and the patient was transported to the hospital. She had an ischemic EKG and elevated troponin. Chest CT showed emphysematous lungs, bilateral rib fractures, and a small right-sided pneumothorax. Despite aggressive measures, the patient's condition gradually worsened, and she died 48 hours after presentation. Discussion/Conclusion: Migration of AM-CPR device pistons may contribute to the development of iatrogenic injuries such as hemopneumothoraces. Patients with underlying lung disease may be at a higher risk of developing pneumothoraces or hemopneumothoraces during the course of AM-CPR. Awareness of these potential complications may aid first responders by improving vigilance of piston location and by providing quicker recognition of iatrogenic injuries that need immediate attention to improve the opportunity for ROSC.
Collapse
|
17
|
Sheldon RR, Do WS, Forte DM, Weiss JB, Derickson MJ, Eckert MJ, Martin MJ. An Evaluation of a Novel Medical Device Versus Standard Interventions in the Treatment of Tension Pneumothorax in a Swine Model (Sus scrofa). Mil Med 2020; 185:125-130. [PMID: 31251337 DOI: 10.1093/milmed/usz135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Tension pneumothorax is a common cause of preventable death in trauma. Needle decompression is the traditional first-line intervention but has high failure rates. We sought to evaluate the effectiveness and expedience of needle thoracostomy, surgical tube thoracostomy, and Reactor™ thoracostomy - a novel spring-loaded trocar insertion device. MATERIALS AND METHODS Yorkshire swine underwent controlled thoracic insufflation to create tension pneumothorax physiology for device comparison. Additional experiments were performed by increasing insufflation pressures to achieve pulseless electrical activity. Intervention was randomized to needle thoracostomy (14 gauge), tube thoracostomy (32Fr), or Reactor™ thoracostomy (36Fr). Air leak was simulated throughout intervention with 40-80 mL/kg/min insufflation. Intrathoracic pressure monitoring and hemodynamic parameters were obtained at 1 and 5 minutes. RESULTS Tension physiology and tension-induced pulseless electrical activity were created in all iterations. Needle thoracostomy (n = 28) was faster at 7.04 ± 3.04 seconds than both Reactor thoracostomy (n = 32), 11.63 ± 5.30 (p < 0.05) and tube thoracostomy (n = 32), 27.06 ± 10.73 (p < 0.01); however, Reactor™ thoracostomy was faster than tube thoracostomy (p < 0.001). Physiological decompression was achieved in all patients treated with Reactor™ and tube thoracostomy, but only 14% of needle thoracostomy. Cardiac recovery to complete physiologic baseline occurred in only 21% (6/28) of those treated with needle thoracostomy whereas Reactor™ or tube thoracostomy demonstrated 88% (28/32) and 94% (30/32) response rates. When combined, needle thoracostomy successfully treated tension pneumothorax in only 4% (1/28) of subjects as compared to 88% (28/32) with Reactor™ thoracostomy and 94% (30/32) with tube thoracostomy (p < 0.01). CONCLUSIONS Needle thoracostomy provides a rapid intervention for tension pneumothorax, but is associated with unacceptably high failure rates. Reactor™ thoracostomy was effective, expedient, and may provide a useful and technically simpler first-line treatment for tension pneumothorax or tension-induced pulseless electrical activity.
Collapse
Affiliation(s)
- Rowan R Sheldon
- Department of Surgery, ATTN: MCHJ-SSS-G, Madigan Army Medical Center; 9040 Jackson Avenue, Tacoma, WA 98431
| | - Woo S Do
- Department of Surgery, ATTN: MCHJ-SSS-G, Madigan Army Medical Center; 9040 Jackson Avenue, Tacoma, WA 98431
| | - Dominic M Forte
- Department of Surgery, ATTN: MCHJ-SSS-G, Madigan Army Medical Center; 9040 Jackson Avenue, Tacoma, WA 98431
| | - Jessica B Weiss
- Department of Surgery, ATTN: MCHJ-SSS-G, Madigan Army Medical Center; 9040 Jackson Avenue, Tacoma, WA 98431
| | - Michael J Derickson
- Department of Surgery, ATTN: MCHJ-SSS-G, Madigan Army Medical Center; 9040 Jackson Avenue, Tacoma, WA 98431
| | - Matthew J Eckert
- Department of Surgery, ATTN: MCHJ-SSS-G, Madigan Army Medical Center; 9040 Jackson Avenue, Tacoma, WA 98431
| | - Matthew J Martin
- Trauma and Emergency General Surgery Service, Scripps Mercy Medical Center, 4077 5th Avenue, San Diego, CA 92103
| |
Collapse
|
18
|
Hick JL, Nelson J, Fildes J, Kuhls D, Eastman A, Dries D. Triage, Trauma, and Today's Mass Violence Events. J Am Coll Surg 2020; 230:251-256. [DOI: 10.1016/j.jamcollsurg.2019.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
|
19
|
DeArmond DT, Das NA, Restrepo CS, Katona MA, Johnson SB, Hernandez BS, Michalek JE. Intrapleural Impedance Sensor Real-Time Tracking of Pneumothorax in a Porcine Model of Air Leak. Semin Thorac Cardiovasc Surg 2019; 32:357-366. [PMID: 31610232 DOI: 10.1053/j.semtcvs.2019.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 11/11/2022]
Abstract
In patients with alveolar-to-pleural air leak due to recent surgery or trauma, clinicians tend to manage chest tubes with suction therapy. Nonsuction therapy is associated with shorter chest tube duration but also a higher risk of pneumothorax. We sought to develop an intrapleural electrical impedance sensor for continuous, real-time monitoring of pneumothorax development in a porcine model of air leak as a means of promoting nonsuction therapy. Using thoracoscopy, 2 chest tubes and the pleural impedance sensor were introduced into the pleural space of 3 pigs. Continuous air leak was introduced through 1 chest tube by carbon dioxide insufflation. The second chest tube was placed to suction then transitioned to no suction at increasingly higher air leaks until pneumothorax developed. Simultaneously, real-time impedance measurements were obtained from the pleural sensor. Fluoroscopy spot images were captured to verify the presence or absence of pneumothorax. Statistical Analysis Software was used throughout. With the chest tube on suction, a fully expanded lung was identified by a distinct pleural electrical impedance respiratory waveform. With transition of the chest tube to water seal, loss of contact of the sensor with the lung resulted in an immediate measurement of infinite electrical impedance. Pneumothorax resolution by restoring suction therapy was detected in real time by a return of the normal respiratory impedance waveform. Pleural electrical impedance monitoring detected pneumothorax development and resolution in real time. This simple technology has the potential to improve the safety and quality of chest tube management.
Collapse
Affiliation(s)
- Daniel T DeArmond
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, Texas.
| | - Nitin A Das
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, Texas
| | | | - Mitch A Katona
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, Texas
| | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, Texas
| | - Brian S Hernandez
- Department of Epidemiology & Biostatistics, UTHSCSA, San Antonio, Texas
| | - Joel E Michalek
- Department of Epidemiology & Biostatistics, UTHSCSA, San Antonio, Texas
| |
Collapse
|
20
|
Quinn N, Palmer CS, Bernard S, Noonan M, Teague WJ. Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia. Emerg Med Australas 2019; 32:117-126. [PMID: 31531952 DOI: 10.1111/1742-6723.13392] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 07/08/2019] [Accepted: 07/29/2019] [Indexed: 12/18/2022]
Abstract
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.].
Collapse
Affiliation(s)
- Nuala Quinn
- Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Temple Street Children's University Hospital, Dublin, Ireland
| | - Cameron S Palmer
- Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Michael Noonan
- Alfred Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Warwick J Teague
- Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatric Surgery, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Surgical Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
21
|
Gurney D. Tension Pneumothorax: What Is an Effective Treatment? J Emerg Nurs 2019; 45:584-587. [PMID: 31445632 DOI: 10.1016/j.jen.2019.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 11/17/2022]
|
22
|
Lesperance RN, Carroll CM, Aden JK, Young JB, Nunez TC. Failure Rate of Prehospital Needle Decompression for Tension Pneumothorax in Trauma Patients. Am Surg 2018. [DOI: 10.1177/000313481808401130] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Colin M. Carroll
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James K. Aden
- Department of Graduate Medical Education, Brooke Army Medical Center, San Antonio, Texas
| | - Jason B. Young
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Timothy C. Nunez
- Division of Trauma and Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
23
|
Kirkpatrick AW, McKee JL, Netzer I, McBeth PB, D'Amours S, Kock V, Dobron A, Ball CG, Glassberg E. Transoceanic Telementoring of Tube Thoracostomy Insertion: A Randomized Controlled Trial of Telementored Versus Unmentored Insertion of Tube Thoracostomy by Military Medical Technicians. Telemed J E Health 2018; 25:730-739. [PMID: 30222511 DOI: 10.1089/tmj.2018.0138] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Andrew W Kirkpatrick
- 1Regional Trauma Services, University of Calgary, Calgary, Canada.,2Canadian Forces Medical Services, Ottawa, Canada
| | - Jessica L McKee
- 1Regional Trauma Services, University of Calgary, Calgary, Canada.,2Canadian Forces Medical Services, Ottawa, Canada
| | | | - Paul B McBeth
- 1Regional Trauma Services, University of Calgary, Calgary, Canada
| | | | - Volker Kock
- 2Canadian Forces Medical Services, Ottawa, Canada
| | - Alex Dobron
- 3Israeli Defence Force Medical Corp, Haifa, Israel
| | - Chad G Ball
- 1Regional Trauma Services, University of Calgary, Calgary, Canada
| | - Elon Glassberg
- 3Israeli Defence Force Medical Corp, Haifa, Israel.,5Faculty of Medicine, Bar-Ilan University, Safed, Israel.,6The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| |
Collapse
|
24
|
A Novel Expeditionary Perfused Cadaver Model for Trauma Training in the Out-of-Hospital Setting. J Emerg Med 2018; 55:383-389. [PMID: 30064710 DOI: 10.1016/j.jemermed.2018.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 04/29/2018] [Accepted: 05/30/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cadaver training for prehospital surgical procedures is a valid training model. The limitation to date has been that perfused cadavers have only been used in wet laboratories in hospitals or university centers. We endeavor to describe a transportable central-perfused cadaver model suitable for training in the battlefield environment. Goals of design were to create a simple, easily reproducible, and realistic model to simulate procedures in field and austere conditions. METHODS We conducted a review of the published literature on cadaver models, conducted virtual-reality simulator training, performed interviews with subject matter experts, and visited the laboratories at the Centre for Emergency Health Sciences in Spring Branch, TX, the Basic Endovascular Skills in Trauma laboratory in Baltimore, MD, and the Fresh Tissue Dissection Laboratory at Los Angeles County and University of Southern California, Keck School of Medicine, Los Angeles, CA. PROCEDURE This article will describe a five-step procedure that utilizes extremity tourniquets, right common carotid intra-arterial and distal femur intraosseous (IO) access for perfusion, and oropharynx preparation for airway procedures. The model will then be ready for all tactical combat casualty care procedures, including nasopharyngeal airway, endotracheal intubation, cricothyroidotomy, central-line access, needle decompression, finger and tube thoracostomy, resuscitative endovascular balloon occlusion of the aorta, junctional tourniquets, IO lines, and field amputations. CONCLUSIONS This model has been used in the laboratory, field, ground ambulance, and military air ambulance (UH-60) settings with good results. The model described can be used in the field setting with minimal resources and accurately simulates the critical skills for all combat trauma procedures.
Collapse
|
25
|
Dickson RL, Gleisberg G, Aiken M, Crocker K, Patrick C, Nichols T, Mason C, Fioretti J. Emergency Medical Services Simple Thoracostomy for Traumatic Cardiac Arrest: Postimplementation Experience in a Ground-based Suburban/Rural Emergency Medical Services Agency. J Emerg Med 2018; 55:366-371. [PMID: 29958708 DOI: 10.1016/j.jemermed.2018.05.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/16/2018] [Accepted: 05/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Tube thoracostomy has long been the standard of care for treatment of tension pneumothorax in the hospital setting yet is uncommon in prehospital care apart from helicopter emergency medical services. OBJECTIVE We aimed to evaluate the performance of simple thoracostomy (ST) for patients with traumatic cardiac arrest and suspected tension pneumothorax. METHODS We conducted a retrospective case series of consecutive patients with traumatic cardiac arrest where simple thoracostomy was used during the resuscitation effort. Data were abstracted from our Zoll emergency medical record (Zoll Medical Corp., Chelmsford, MA) for patients who received the procedure between June 1, 2013 and July 1, 2017. We collected general descriptive characteristics, procedural success, presence of air or blood, and outcomes for each patient. RESULTS During the study period we performed ST on 57 patients. The mean age was 41 years old (range 15-81 years old) and 83% were male. Indications included 40 of 57 (70%) blunt trauma and 17 of 57 (30%) penetrating trauma. The presenting rhythm was pulseless electrical activity 65%, asystole 26%, ventricular tachycardia/fibrillation 4%, and nonrecorded 5%. Eighteen of 57 (32%) had air return, 14 of 57 (25%) return of spontaneous circulation, with 6 of 57 (11%) surviving to 24 h and 4 of 57 (7%) discharged from the hospital neurologically intact. Of the survivors, all were blunt trauma mechanism with initial rhythms of pulseless electrical activity. There were no reported medic injuries. CONCLUSIONS Our data show that properly trained paramedics in ground-based emergency medical services were able to safely and effectively perform ST in patients with traumatic cardiac arrest. We found a significant (32%) presence of pneumothorax in our sample, which supports previously reported high rates in this patient population.
Collapse
Affiliation(s)
| | | | - Michael Aiken
- Montgomery County Hospital District Emergency Medical Services, Houston, Texas
| | - Kevin Crocker
- Montgomery County Hospital District Emergency Medical Services, Houston, Texas
| | - Casey Patrick
- Montgomery County Hospital District Emergency Medical Services, Houston, Texas
| | - Tyler Nichols
- Baylor College of Medicine, Baylor University, Houston, Texas
| | | | - Joseph Fioretti
- Montgomery County Hospital District Emergency Medical Services, Houston, Texas
| |
Collapse
|
26
|
DeArmond DT, Das NA, Restrepo CS, Johnson SB, Michalek JE, Hernandez BS. Pleural electrical impedance is a sensitive, real-time indicator of pneumothorax. J Surg Res 2018; 231:15-23. [PMID: 30278922 DOI: 10.1016/j.jss.2018.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/21/2018] [Accepted: 05/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chest tube management protocols, particularly in patients with alveolar-pleural air leak due to recent surgery or trauma, are limited by concerns over safety, especially concerns about rapid and occult development of pneumothorax. A continuous, real-time monitor of pneumothorax could improve the quality and safety of chest tube management. We developed a rat model of pneumothorax to test a novel approach of measuring electrical impedance within the pleural space as a monitor of lung expansion. MATERIALS AND METHODS Anesthetized Sprague-Dawley rats underwent right thoracotomy. A novel impedance sensor and a thoracostomy tube were introduced into the right pleural space. Pneumothorax of varying volumes ranging from 0.2 to 20 mL was created by syringe injection of air via the thoracostomy tube. Electrical resistance measurements from the pleural sensor and fluoroscopic images were obtained at baseline and after the creation of pneumothorax and results compared. RESULTS A statistically significant, dose-dependent increase in electrical resistance was observed with increasing volume of pneumothorax. Resistance measurement allowed for continuous, real-time monitoring of pneumothorax development and the ability to track pneumothorax resolution by aspiration of air via the thoracostomy tube. Pleural resistance measurement demonstrated 100% sensitivity and specificity for all volumes of pneumothorax tested and was significantly more sensitive for pneumothorax detection than fluoroscopy. CONCLUSIONS The electrical impedance-based pleural space sensor described in this study provided sensitive and specific pneumothorax detection, which was superior to radiographic analysis. Real-time, continuous monitoring for pneumothorax has the potential to improve the safety, quality, and efficiency of postoperative chest tube management.
Collapse
Affiliation(s)
- Daniel T DeArmond
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
| | - Nitin A Das
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Carlos S Restrepo
- Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Joel E Michalek
- Department of Epidemiology & Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Brian S Hernandez
- Department of Epidemiology & Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| |
Collapse
|
27
|
Kuckelman J, Derickson M, Phillips C, Barron M, Marko S, Eckert M, Martin M. Evaluation of a novel thoracic entry device versus needle decompression in a tension pneumothorax swine model. Am J Surg 2018; 215:832-835. [DOI: 10.1016/j.amjsurg.2017.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/03/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
|
28
|
Kuckelman J, Cuadrado D, Martin M. Thoracic Trauma: a Combat and Military Perspective. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0112-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
29
|
Leatherman ML, Fluke LM, McEvoy CS, Pokorny DM, Ricca RL, Martin MJ, Gamble CS, Polk TM. Bigger is better: Comparison of alternative devices for tension hemopneumothorax and pulseless electrical activity in a Yorkshire swine model. J Trauma Acute Care Surg 2017; 83:1187-1194. [DOI: 10.1097/ta.0000000000001684] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
30
|
Abstract
Management of chest trauma is integral to patient outcomes owing to the vital structures held within the thoracic cavity. Understanding traumatic chest injuries and appropriate management plays a pivotal role in the overall well-being of both blunt and penetrating trauma patients. Whether the injury includes rib fractures, associated pulmonary injuries, or tracheobronchial tree injuries, every facet of management may impact the short- and long-term outcomes, including mortality. This article elucidates the workup and management of the thoracic cage, pulmonary and tracheobronchial injuries.
Collapse
Affiliation(s)
- Bradley M Dennis
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Seth A Bellister
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| |
Collapse
|
31
|
Caap P, Aagaard R, Sloth E, Løfgren B, Granfeldt A. Reduced right ventricular diameter during cardiac arrest caused by tension pneumothorax - a porcine ultrasound study. Acta Anaesthesiol Scand 2017; 61:813-823. [PMID: 28555810 DOI: 10.1111/aas.12911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/29/2017] [Accepted: 05/03/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Advanced life support (ALS) guidelines recommend ultrasound to identify reversible causes of cardiac arrest. Right ventricular (RV) dilatation during cardiac arrest is commonly interpreted as a sign of pulmonary embolism. The RV is thus a focus of clinical ultrasound examination. Importantly, in animal studies ventricular fibrillation and hypoxia results in RV dilatation. Tension pneumothorax (tPTX) is another reversible cause of cardiac arrest, however, the impact on RV diameter remains unknown. AIM To investigate RV diameter evaluated by ultrasound in cardiac arrest caused by tPTX or hypoxia. METHODS Pigs were randomized to cardiac arrest by either tPTX (n = 9) or hypoxia (n = 9) and subsequently resuscitated. Tension pneumothorax was induced by injection of air into the pleural cavity. Hypoxia was induced by reducing tidal volume. Ultrasound images of the RV were obtained throughout the study. Tension pneumothorax was decompressed after the seventh rhythm analysis. The primary endpoint was RV diameter after the third rhythm analysis. RESULTS At cardiac arrest the RV diameter was 17 mm (95% CI: 13; 21) in the tPTX group and 36 mm (95% CI: 33; 40) in the hypoxia group (P < 0.01, n = 9 for both). At third rhythm analysis RV diameter was smaller in the tPTX group: 12 mm (95% CI: 7; 16) vs. hypoxia group: 28 mm (25; 32) (P < 0.01). After decompression no difference existed between groups: tPTX 29 mm (95% CI: 23; 34) vs. hypoxia 29 mm (95% CI: 20; 38). CONCLUSION The RV diameter is smaller during cardiopulmonary resuscitation in cardiac arrest caused by tPTX when compared with hypoxia. The difference disappears after tPTX decompression.
Collapse
Affiliation(s)
- P. Caap
- Research Center for Emergency Medicine; Aarhus University Hospital; Aarhus Denmark
| | - R. Aagaard
- Research Center for Emergency Medicine; Aarhus University Hospital; Aarhus Denmark
- Department of Anesthesiology; Regional Hospital of Randers; Randers Denmark
- Clinical Research Unit; Regional Hospital of Randers; Randers Denmark
| | - E. Sloth
- Department of Anesthesiology and Intensive Care Medicine East Section; Aarhus University Hospital; Aarhus Denmark
- University of Cape Town; Cape Town South Africa
| | - B. Løfgren
- Research Center for Emergency Medicine; Aarhus University Hospital; Aarhus Denmark
- Department of Internal Medicine; Regional Hospital of Randers; Randers Denmark
- Institute of Clinical Medicine; Aarhus University; Aarhus Denmark
| | - A. Granfeldt
- Institute of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Anaesthesiology and Intensive Care South Section; Aarhus University Hospital; Aarhus Denmark
| |
Collapse
|
32
|
Relative device stability of anterior versus axillary needle decompression for tension pneumothorax during casualty movement. J Trauma Acute Care Surg 2017; 83:S136-S141. [DOI: 10.1097/ta.0000000000001488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
Littlejohn LF. Treatment of Thoracic Trauma: Lessons From the Battlefield Adapted to All Austere Environments. Wilderness Environ Med 2017; 28:S69-S73. [DOI: 10.1016/j.wem.2017.01.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 01/05/2017] [Accepted: 01/27/2017] [Indexed: 12/17/2022]
|
34
|
Naik ND, Hernandez MC, Anderson JR, Ross EK, Zielinski MD, Aho JM. Needle Decompression of Tension Pneumothorax with Colorimetric Capnography. Chest 2017; 152:1015-1020. [PMID: 28499514 DOI: 10.1016/j.chest.2017.04.179] [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] [Received: 01/22/2017] [Revised: 03/06/2017] [Accepted: 04/29/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The success of needle decompression for tension pneumothorax is variable, and there are no objective measures assessing effective decompression. Colorimetric capnography, which detects carbon dioxide present within the pleural space, may serve as a simple test to assess effective needle decompression. METHODS Three swine underwent traumatically induced tension pneumothorax (standard of care, n = 15; standard of care with needle capnography, n = 15). Needle thoracostomy was performed with an 8-cm angiocatheter. Similarly, decompression was performed with the addition of colorimetric capnography. Subjective operator assessment of decompression was recorded and compared with true decompression, using thoracoscopic visualization for both techniques. Areas under receiver operating curves were calculated and pairwise comparison was performed to assess statistical significance (P < .05). RESULTS The detection of decompression by needle colorimetric capnography was found to be 100% accurate (15 of 15 attempts), when compared with thoracoscopic assessment (true decompression). Furthermore, it accurately detected the lack of tension pneumothorax, that is, the absence of any pathologic/space-occupying lesion, in 100% of cases (10 of 10 attempts). Standard of care needle decompression was detected by operators in 9 of 15 attempts (60%) and was detected in 3 of 10 attempts when tension pneumothorax was not present (30%). True decompression, under direct visualization with thoracoscopy, occurred 15 of 15 times (100%) with capnography, and 12 of 15 times (80%) without capnography. Areas under receiver operating curves were 0.65 for standard of care and 1.0 for needle capnography (P = .002). CONCLUSIONS Needle decompression with colorimetric capnography provides a rapid, effective, and highly accurate method for eliminating operator bias for tension pneumothorax decompression. This may be useful for the treatment of this life-threatening condition.
Collapse
Affiliation(s)
- Nimesh D Naik
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Matthew C Hernandez
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Jeff R Anderson
- Office of Translation to Practice, Mayo Clinic, Rochester, MN
| | - Erika K Ross
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Martin D Zielinski
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Johnathon M Aho
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN.
| |
Collapse
|
35
|
Do vented chest seals differ in efficacy? An experimental evaluation using a swine hemopneumothorax model. J Trauma Acute Care Surg 2017; 83:182-189. [PMID: 28422911 DOI: 10.1097/ta.0000000000001501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Airways compromise was the second leading cause of potentially preventable death among combat casualties. We investigated the ability of five Food and Drug Administration-approved nonocclusive chest seals (CSs) to seal a bleeding chest wound and prevent tension hemopneumothorax (HPTX) in a swine model. METHODS Following instrumentation, an open chest wound was created in the left thorax of spontaneously air-breathing anesthetized pigs (n = 26; 43 kg). Autologous fresh blood (226 mL) was then infused into the pleural cavity to produce HPTX. The chest wounds were then sealed with CSs. The sealant strength and venting function of CSs were challenged by infusion of 50 mL more blood directly into the chest wound and incremental air injections into the pleural cavity. Tension HPTX was defined as intrapleural (IP) pressure equal to or more than +1 mm Hg and more than 20% deviation in physiologic measurements. RESULTS An open chest wound with HPTX raised IP pressure (~ -0.7 mm Hg) and caused labored breathing and reductions in PaO2 and SvO2 (p < 0.01). Sealing the wounds with the CSs restored IP pressure, and improved breathing and oxygenation. Subsequent blood infusion into the wound and IP air injections produced CS-dependent responses. Chest seals with one-way valves (Bolin and SAM) did not evacuate the blood efficiently; pooled blood either detached the CSs from skin and leaked out (75%), or clotted and clogged the valve and led to tension HPTX (25%). Conversely, CSs with laminar venting channels allowed escape of blood and air from the pleural cavity and maintained IP pressure and oxygenation near normal levels. Success rates were 100% for Sentinel and Russell (6/6); 67% for HyFin (4/6); 25% for SAM (1/4); and 0% for Bolin (0/4) CSs (p = 0.002). CONCLUSION The sealant and valve function of vented CS differed widely in the presence of bleeding chest wounds. Medics should be equipped with more effective CSs for treating HPTX in the field.
Collapse
|
36
|
Ozen C, Akoglu H, Ozdemirel RO, Omeroglu E, Ozpolat CU, Onur O, Buyuk Y, Denizbasi A. Determination of the chest wall thicknesses and needle thoracostomy success rates at second and fifth intercostal spaces: a cadaver-based study. Am J Emerg Med 2016; 34:2310-2314. [DOI: 10.1016/j.ajem.2016.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 08/16/2016] [Accepted: 08/16/2016] [Indexed: 11/28/2022] Open
|
37
|
Kaserer A, Stein P, Simmen HP, Spahn DR, Neuhaus V. Failure rate of prehospital chest decompression after severe thoracic trauma. Am J Emerg Med 2016; 35:469-474. [PMID: 27939518 DOI: 10.1016/j.ajem.2016.11.057] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/21/2016] [Accepted: 11/28/2016] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Chest decompression can be performed by different techniques, like needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT). The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effectiveness of these techniques. MATERIAL AND METHODS In this retrospective case series study, all medical records of adult trauma patients undergoing prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied. RESULTS In a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen patients had NT, six patients TT, one patient NT as well as TT, and no patients had LT. Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT related complications were reported during hospitalization. CONCLUSION Prehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission.
Collapse
Affiliation(s)
- Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Philipp Stein
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Hans-Peter Simmen
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Valentin Neuhaus
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| |
Collapse
|
38
|
High K, Brywczynski J, Guillamondegui O. Safety and Efficacy of Thoracostomy in the Air Medical Environment. Air Med J 2016; 35:227-230. [PMID: 27393758 DOI: 10.1016/j.amj.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 03/18/2016] [Accepted: 04/02/2016] [Indexed: 06/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Kevin High
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, TN.
| | - Jeremy Brywczynski
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, TN
| | - Oscar Guillamondegui
- Division of Trauma and Surgical Critical Care, Vanderbilt Medical Center, Nasville, TN
| |
Collapse
|
39
|
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.
Collapse
|
40
|
Wernick B, Hon HH, Mubang RN, Cipriano A, Hughes R, Rankin DD, Evans DC, Burfeind WR, Hoey BA, Cipolla J, Galwankar SC, Papadimos TJ, Stawicki SP, Firstenberg MS. Complications of needle thoracostomy: A comprehensive clinical review. Int J Crit Illn Inj Sci 2015; 5:160-9. [PMID: 26557486 PMCID: PMC4613415 DOI: 10.4103/2229-5151.164939] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Brian Wernick
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Heidi H Hon
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Ronnie N Mubang
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Anthony Cipriano
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Ronson Hughes
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Demicha D Rankin
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - David C Evans
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - William R Burfeind
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Brian A Hoey
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - James Cipolla
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Sagar C Galwankar
- Department of Emergency Medicine, University of Florida, Jacksonville, Florida, United States
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Stanislaw P Stawicki
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States ; Department of Research and Innovation, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Michael S Firstenberg
- Cardiothoracic Surgery, Summa Health System and Northeastern Ohio Universities College of Medicine, Akron, Ohio, United States
| |
Collapse
|
41
|
Smith JE, Le Clerc S, Hunt PAF. Challenging the dogma of traumatic cardiac arrest management: a military perspective. Emerg Med J 2015; 32:955-60. [PMID: 26493124 DOI: 10.1136/emermed-2015-204684] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 09/28/2015] [Indexed: 11/04/2022]
Abstract
Attempts to resuscitate patients in traumatic cardiac arrest (TCA) have, in the past, been viewed as futile. However, reported outcomes from TCA in the past five years, particularly from military series, are improving. The pathophysiology of TCA is different to medical causes of cardiac arrest, and therefore, treatment priorities may also need to be different. This article reviews recent literature describing the pathophysiology of TCA and describes how the military has challenged the assumption that outcome is universally poor in these patients.
Collapse
Affiliation(s)
- J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, Derriford Hospital, Plymouth, UK
| | - S Le Clerc
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, James Cook University Hospital, Middlesbrough, UK
| | - P A F Hunt
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK Emergency Department, James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
42
|
Penetrating Injuries to the Lung and Heart: Resuscitation, Diagnosis, and Operative Indications. CURRENT TRAUMA REPORTS 2015. [DOI: 10.1007/s40719-015-0025-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
Abstract
Traumatic cardiac arrest is known to have a poor outcome, and some authors have stated that attempted resuscitation from traumatic cardiac arrest is futile. However, advances in damage control resuscitation and understanding of the differences in pathophysiology of traumatic cardiac arrest compared to medical cardiac arrest have led to unexpected survivors. Recently published data have suggested that outcome from traumatic cardiac arrest is no worse than that for medical causes of cardiac arrest, and in some groups may be better. This review highlights key areas of difference between traumatic cardiac arrest and medical cardiac arrest, and outlines a strategy for the management of patients in traumatic cardiac arrest. Standard Advanced Life Support algorithms should not be used for patients in traumatic cardiac arrest.
Collapse
Affiliation(s)
- Jason E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| | | | - David Wise
- Emergency Department, Derriford Hospital, Plymouth, UK
| |
Collapse
|
45
|
Nadeldekompression des Spannungspneumothorax. Notf Rett Med 2015. [DOI: 10.1007/s10049-014-1951-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
46
|
Penetrating cardiac injury as the result of pre-hospital needle decompression. Heart Lung Circ 2015. [DOI: 10.1016/j.hlc.2014.12.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
47
|
Abstract
Critically ill patients with undifferentiated shock are complex and challenging cases in the ED. A systematic approach to assessment and management is essential to prevent unnecessary morbidity and mortality. The simplified, systematic approach described in this article focuses on determining the presence of problems with cardiac function (the pump), intravascular volume (the tank), or systemic vascular resistance (the pipes). With this approach, the emergency physician can detect life-threatening conditions and implement time-sensitive therapy.
Collapse
Affiliation(s)
- David A Wacker
- Emergency Medicine/Internal Medicine/Critical Care Program, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
| | - Michael E Winters
- Emergency Medicine/Internal Medicine/Critical Care Program, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| |
Collapse
|
48
|
Powers WF, Clancy TV, Adams A, West TC, Kotwall CA, Hope WW. Proper catheter selection for needle thoracostomy: a height and weight-based criteria. Injury 2014; 45:107-11. [PMID: 24064394 DOI: 10.1016/j.injury.2013.08.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 08/20/2013] [Accepted: 08/28/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Obesity increases the incidence of mortality in trauma patients. Current Advanced Trauma Life Support guidelines recommend using a 5-cm catheter at the second intercostal (ICS) space in the mid-clavicular line to treat tension pneumothoraces. Our study purpose was to determine whether body mass index (BMI) predicted the catheter length needed for needle thoracostomy. METHODS We retrospectively reviewed trauma patients undergoing chest computed tomography scans January 2004 through September 2006. A BMI was calculated for each patient, and the chest wall thickness (CWT) at the second ICS in the mid-clavicular line was measured bilaterally. Patients were grouped by BMI as underweight (≤ 18.5 kg/m2), normal weight (18.6-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), or obese (≥ 30 kg/m(2)). RESULTS Three hundred twenty-six patients were included in the study; 70% were male. Ninety-four percent of patients experienced blunt trauma. Sixty-three percent of patients were involved in a motor vehicle collision. The average BMI was 29 [SD 7.8]. The average CWT was 6.2 [SD 1.9]cm on the right and 6.3 [SD 1.9]cm on the left. As BMI increased, a statistically significant (p<0.0001) CWT increase was observed in all BMI groups. There were no significant differences in ISS, ventilator days, ICU length of stay, or overall length of stay among the groups. CONCLUSION As BMI increases, there is a direct correlation to increasing CWT. This information could be used to quickly select an appropriate needle length for needle thoracostomy. The average patient in our study would require a catheter length of 6-6.5 cm to successfully decompress a tension pneumothorax. There are not enough regionally available data to define the needle lengths needed for needle thoracostomy. Further study is required to assess the feasibility and safety of using varying catheter lengths.
Collapse
Affiliation(s)
- William F Powers
- Department of Surgery, South East Area Health Education Center, Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC, United States
| | | | | | | | | | | |
Collapse
|
49
|
Klein KR. Traumatic cardiac arrests--the action or the provider, what makes the difference? Crit Care 2013; 17:156. [PMID: 23786921 PMCID: PMC3706828 DOI: 10.1186/cc12720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Traumatic cardiac arrest resuscitation is considered a heroic and futile endeavor. However, newer articles have more promising statistics and divide between prehospital ground and helicopter transport. Here we discuss why there might be a difference in the survivability of this subset of trauma patients.
Collapse
|
50
|
Sherren PB, Reid C, Habig K, Burns BJ. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care 2013; 17:308. [PMID: 23510195 PMCID: PMC3672499 DOI: 10.1186/cc12504] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Survival rates following traumatic cardiac arrest (TCA) are known to be poor but resuscitation is not universally futile. There are a number of potentially reversible causes to TCA and a well-defined group of survivors. There are distinct differences in the pathophysiology between medical cardiac arrests and TCA. The authors present some of the key differences and evidence related to resuscitation in TCA, and suggest a separate algorithm for the management of out-of-hospital TCA attended by a highly trained physician and paramedic team.
Collapse
|