Prehospital Decompression of Pneumothorax: A Systematic Review of Recent Evidence

Introduction: Pneumothorax remains an important cause of preventable trauma death. The aim of this systematic review is to synthesize the recent evidence on the efficacy, patient outcomes, and adverse events of different chest decompression approaches relevant to the out-of-hospital setting. Methods: A comprehensive literature search was performed using five databases (from January 1, 2014 through June 15, 2020). To be considered eligible, studies required to report original data on decompression of suspected or proven traumatic pneumothorax and be considered relevant to the prehospital context. They also required to be conducted mostly on an adult population (expected more than ≥80% of the population ≥16 years old) of patients. Needle chest decompression (NCD), finger thoracostomy (FT), and tube thoracostomy were considered. No meta-analysis was performed. Level of evidence was assigned using the Harbour and Miller system. Results: A total of 1,420 citations were obtained by the search strategy, of which 20 studies were included. Overall, the level of evidence was low. Eleven studies reported on the efficacy and patient outcomes following chest decompression. The most studied technique was NCD (n = 7), followed by FT (n = 5). Definitions of a successful chest decompression were heterogeneous. Subjective improvement following NCD ranged between 18% and 86% (n = 6). Successful FT was reported for between 9.7% and 32.0% of interventions following a traumatic cardiac arrest. Adverse events were infrequently reported. Nine studies presented only on anatomical measures with predicted failure and success. The mean anterior chest wall thickness (CWT) was larger than the lateral CWT in all studies except one. The predicted success rate of NCD ranged between 90% and 100% when using needle >7cm (n = 7) both for the lateral and anterior approaches. The reported risk of iatrogenic injuries was higher for the lateral approach, mostly on the left side because of the proximity with the heart. Conclusions: Based on observational studies with a low level of evidence, prehospital NCD should be performed using a needle >7cm length with either a lateral or anterior approach. While FT is an interesting diagnostic and therapeutic approach, evidence on the success rates and complications is limited. High-quality studies are required to determine the optimal chest decompression approach applicable in the out-of-hospital setting.

A Pilot Study to Assess Urban, Fire-Based Paramedic Accuracy in Identification of Anatomical Landmarks Necessary for Cricothyrotomy and Needle Chest Decompression Using Live Patient Models

Background: Cricothyrotomy and chest needle decompression (NDC) have a high failure and complication rate. This article sought to determine whether paramedics can correctly identify the anatomical landmarks for cricothyrotomy and chest NDC. Methods: A prospective study using human models was performed. Paramedics were partnered and requested to identify the location for cricothyrotomy and chest NDC (both mid-clavicular and anterior axillary sites) on each other. A board-certified or board-eligible emergency medicine physician timed the process and confirmed location accuracy. All data were collected de-identified. Descriptive analysis was performed on continuous data; chi-square was used for categorical data. Results: A total of 69 participants were recruited, with one excluded for incomplete data. The paramedics had a range of six to 38 (median 14) years of experience. There were 28 medical training officers (MTOs) and 41 field paramedics. Cricothyroidotomy location was correctly identified in 56 of 68 participants with a time to identification range of 2.0 to 38.2 (median 8.6) seconds. Chest NDC (mid-clavicular) location was correctly identified in 54 of 68 participants with a time to identification range of 3.4 to 25.0 (median 9.5) seconds. Chest NDC (anterior axillary) location was correctly identified in 43 of 68 participants with a time to identification range of 1.9 to 37.9 (median 9.6) seconds. Chi-square (2-tail) showed no difference between MTO and field paramedic in cricothyroidotomy site (P = .62), mid-clavicular chest NDC site (P = .21), or anterior axillary chest NDC site (P = .11). There was no difference in time to identification for any procedure between MTO and field paramedic. Conclusion: Both MTOs and field paramedics were quick in identifying correct placement of cricothyroidotomy and chest NDC location sites. While time to identification was clinically acceptable, there was also a significant proportion that did not identify the correct landmarks.

Case Report and Literature Review: Post-Arthroscopy Pneumothorax with Anterior Decompression

Introduction: Emergency providers should recognize that pneumothorax is a rare but serious complication of shoulder arthroscopy that may require a unique approach to decompression. Case Report: We present a case of a 60-year-old female who presented to the emergency department with right-sided facial swelling, voice change, and shortness of breath three hours after an elective arthroscopic right rotator-cuff repair and was noted to have a right-sided pneumothorax. We also describe a potential novel approach to chest tube decompression that maintains shoulder adduction in patients with recently repaired rotator cuffs. Conclusion: Although most cases of post-arthroscopy pneumothoraces are reported in patients who received regional anesthesia or have underlying lung pathology, it can occur in lower-risk patients as was demonstrated in our case. We also suggest considering an alternative anterior approach between the midclavicular and anterior axillary lines for chest decompression in select patients when a traditional approach is less ideal due to the need to maintain shoulder immobilization postoperatively.

A Comparison of Prehospital Nonphysician and Hospital Physician Placed Tube Thoracostomy

Background Prehospital chest decompression can be a lifesaving procedure in severe chest trauma. Studies investigating prehospital chest decompression are mostly European where physicians are assigned to prehospital care units. This report is one of the first to compare demographics and outcomes in patients undergoing prehospital chest decompression by trained aeromedical nonphysician personnel to hospital chest decompression by physicians. Methods Prehospital tube thoracostomy (PTT) patients were identified from January 2014 to January 2019 and were matched in a 1:2 ratio based on age, Injury Severity Score (ISS), and chest Abbreviated Injury Score (AIS) to patients who underwent hospital tube thoracostomy (HTT) within 24 hours of admission. Results Forty-nine PTT patients were matched to 98 HTT patients. PTT patients had lower admission Glasgow Coma Scale (GCS), a higher rate of pre-chest tube needle decompression, and higher level 1 trauma activation. PTT were placed sooner (21.9 vs 157.0 minutes, P < .001). Rates of tube malposition, organ injury, tube dislodgement, empyema, and hospital-acquired pneumonia over the course of hospital admission were not significantly different between the 2 groups. PTT patients had longer intensive care unit length of stay (LOS), but similar hospital LOS, and overall mortality. Discussion This report demonstrates that PTT is performed sooner than hospital placed tubes. Complication rates associated with tube thoracostomy and patient outcomes were not statistically different between PTT and HTT groups.

Bedside Procedures for General Surgeons: Part 1

This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 19 figures, 7 tables, and 33 references. Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown

Bedside Procedures for General Surgeons: Part 1

This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 19 figures, 7 tables, and 33 references. Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown

Bedside Procedures for General Surgeons: Part 1

This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 19 figures, 7 tables, and 33 references. Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown

Anesthetic Complication during Maxillofacial Trauma Surgery: A Case Report of Intraoperative Tension Pneumothorax

Tension pneumothorax is a life-threatening emergency that requires a high index of suspension and immediate intervention to prevent circulatory collapse and death. Only five cases of pneumothorax were described in the Oral and Maxillofacial Surgery literature. All cases were postoperative complications associated with orthognathic surgery. We report a case of intraoperative tension pneumothorax during a routine facial trauma surgery requiring emergency chest decompression. The possible causes, classification, and reported cases will be presented.