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Needle Thoracostomy
trauma.org (8:2) February 2003

From: Jeff Anderson
Date: Tue 17/12/2002 05:25

I would like to find some information about the evidence behind needle decompression of tension pneumothrorax by paramedics. Any information or opinions would be much appreciated.

Jeff Anderson, NREMT-P

From: Elton Farla
Date: Tue 17/12/2002 06:28

Jeff

I have had a few cases that warranted a needle decompression, in both pneumo and heamothroraxes, and most of them have had a positive result.

Elton Farla
Flight medic

From: Jeremy Hsu
Date: Tue 17/12/2002 11:38

Jeff,

Not that much evidence available, but have a look at the following two references.

Title
Needlethoracostomy in the prehospital setting.

Authors
Eckstein M . Suyehara D .

Institution
Department of Emergency Medicine, University of Southern California School of Medicine, Los Angeles 90033, USA. eckstein@hsc.usc.edu

Source
Prehospital Emergency Care. 2(2):132-5, 1998 Apr-Jun.

Abstract
OBJECTIVES: To determine the effect of needlethoracostomy (NT) in the prehospital setting, its frequency of use, and its complication rate. METHODS: This was a prospective case series from January 1, 1995, to December 31, 1996. Inclusion criteria were all patients who met trauma center criteria, were transported by paramedics to Los Angeles County/University of Southern California Medical Center (a large, urban, level I trauma center), and had placement of a prehospital NT. RESULTS: Out of 6,241 major trauma patients transported by paramedics over the study period, 108 (1.7%) underwent 114 NTs. Sixty-four patients (59%) sustained gunshot wounds, 32 (30%) sustained stab wounds, eight (7%) were involved in motor vehicle accidents, and the remainder had other types of blunt trauma. The mean injury severity score (ISS) was 22.3, and the overall mortality rate was 28%. Of the patients who received NTs, five (5%) showed objective improvement in field vital signs and seven (7%) had subjective improvement of their dyspnea. Two NTs were found to have not penetrated into the thorax with the catheter tip in the soft tissue. Two patients (2%) received NTs despite the absence of any chest injuries found upon operative intervention, resulting in two iatrogenic pneumothoraxes. No other complications, including vascular injury or infection, were found in any of the patients. CONCLUSION: Prehospital NT is a procedure infrequently performed by paramedics, even in a busy urban area. While there is a risk of the procedure's being done without proper indication, NT may improve outcomes in a small subset of chest-injured patients.


--------------------------------------------------------------------------------

Title
Needlethoracostomy may not be indicated in the trauma patient.

Authors
Cullinane DC . Morris JA Jr . Bass JG . Rutherford EJ .

Institution
Vanderbilt University Medical Center, Tennessee, Nashville, USA. cullinane.daniel@mayo.edu

Source
Injury. 32(10):749-52, 2001 Dec.

Abstract
OBJECTIVE: The aim of this study was to evaluate the usefulness of needlethoracostomy catheter (NTC) placement in trauma. METHODS: A consecutive case series was conducted from November 1996 to September 1997. All patients admitted to a level I trauma centre who had NTCs placed prior to arrival in the Emergency Department were included. No patients were excluded or omitted. During the course of the study 2801 patients were admitted to our trauma centre. Nineteen patients (0.68%) had NTCs placed prior to arrival in the emergency department. RESULTS: Twenty-five needle thoracostomies were performed in 19 patients. This group represented 0.68% of the trauma admissions. Four patients were found to have evidence of a pneumothorax with an air leak (28%). The NTC failed to decompress the chest in one of two patients who had physiologic evidence of a tension pneumothorax. Eleven patients (58%) were endotracheally intubated prior to NTC. CONCLUSIONS: This study suggests that field NTC placements are often ineffective and may be over-used. Further study on the usefulness of NTC is required.

 

From: Eric Frykberg
Date: Tue 17/12/2002 15:21

I hope everyone can see how clearly the conclusions are NOT AT ALL supported by the presented data--there is nothing in this data that even suggests "improved outcomes"--a classic illustration of how we try to mold our data to fit with our preconceived notions, instead of how it should be--derive conclusions from what we observe. The proper conclusion from this data would be that there appears to be no benefit to prehospital needle thoracostomy, and clear risk--thus the risk:benefit ratio should mandate it not be done.

ERF

From: Mike Bjarkoy
Date: Tue 17/12/2002 12:03

Completly anecdotal.
In the past 16 years as a paramedic I have come across 7 patients that required a needle decompression. 2 Survived (just around the corner from ER) and of the other 5 - 2 would have survived if I had the skills available to hand (both isolated chest trauma) the other 3 would have died even if I could use the skill when I got to the patient.

Mike Bjarkoy
Paramedic
UK

 

From:Tim Noonan
Date: Tue 17/12/2002 16:35

How are you determining who would have survived? Is it based on isolated tension pneumothorax at autopsy while the others are multisystem trauma? Did the survivors have needle decompression in the ED, chest tubes...? Is this now in your scope of practice?

From: Eric Frykberg
Date: Tue 17/12/2002 21:41

How do you know the patients had tension PTX? One of the many problems with anecdotes like this--please clarify?

From: Michael Bjarkoy
Date: Thu 19/12/2002 07:50

Because the A&E Consultants told me so (anecdotal) and they were able to do this because they had chest xrays (evidence) in their hands at the time which identified the TP.

From: Tim Noonan
Date: Thu 19/12/2002 08:04

Everybody DUCK!

Tim Noonan.

From: Ken Mattox
Date: Tue 17/12/2002 15:24

Despite numerous debates on this subject, I still strongly believe that there are basically NO indications for needle decompression of a chest in the prehospital setting, especially in air ambulance operations. I am certain that we will continue to see complications of this invasive, and non-QAed procedure, much like we now see with pericardiocentesis. Remove both from your resuscitation course curriculum

k

From: Tim Noonan
Date: Tue 17/12/2002 15:46

How many of these may have had needlethoracostomy because the patient was
very dead and it couldn't hurt. Given the infrequency of performance
(makes intubation look common) the desire to obtain experience/perform a
skill might skew the numbers.

DocRickFry, the last time I took PHTLS (a couple of years ago) the
instructors made a big deal out of quickly needling the chest of an awake
alert patient with signs of a tension pneumothorax (it is one of the
slides for discussion). What are your thoughts? I assume (ducking here)
in hospital you would sedate and place a chest tube, but in the
prehospital setting with 10+ minutes to the hospital...

I don't suppose the patients who "had subjective improvement of their
dyspnea" might have said "OK, I feel better. Just stop poking me in the
chest with those big needles."

Tim Noonan.

PS I did not agree. They stated that I should not be allowed
around patients.

 

From: Eric Frykberg
Date: Tue 17/12/2002 16:28

I would certainly hope that no health care provider sticks holes in real patients to hone their skills--what happened to patient above all else? Putting a hot rock under the stretcher also can't hurt--why not mention that too?

 

From: Phil Hoffman
Date: Tue 17/12/2002 16:21

Alright, obviously I'm a moron and need someone to walk me through this...

According to the presented data "five (5%) showed objective improvement in field vital signs and seven (7%) had subjective improvement of their dyspnea."

The author then concluded: "NT may improve outcomes in a small subset of chest-injured patients [emphasis mine]."

So, Dr. Frykberg, how does this show that "The proper conclusion from this data would be that there appears to be no benefit."

In my day job, I play with statistics quite a bit and am fond of the expression "Figures don't lie, but liars do figure." Perhaps this little chestnut resides in the paragraphs below?

As an aside, I am curious if the seven percent group includes patients in the five percent group.

Phil Hoffman
EMTP

 

From: Eric Frykberg
Date: Tue 17/12/2002 16:26

You misunderstand me--all I said was the study showed nothing about improved OUTCOMES. Some unfounded claims of post-needle improvement is NOT an improved outcome--outcome relates to their ultimate course--mortality, hospital stay, etc--this muddled confusion of terms is just so typical of schlock science. I made no judgement about needle thoracostomy, only about the quoted study. See Dr Mattox's post regarding the worth of the procedure--which goes along with most of our experiences --most outcomes are of detriment to the patient, in the way of prolonged hospital stay for the iatrogenic pneumothorax, at best. In many, they are of no value--never entered the chest to begin with. I routinely just take the darn things out as soon as I see them in an arriving patient--never in 17 years have I yet seen an adverse consequence of this removal, and the great majority never even then had a pneumothorax! This is despite routinely reading on the run sheet about the "rush of air" when the needle was put in--almost laughable!

ERF

 

From: Robert F Smith
Date: Tue 17/12/2002 19:03

Phil,

You're not a moron; at least you asked.

This appears to be another retrospective analysis of collected data. First of all no definition of "objective improvement" is given in the abstract. The conclusions talk about improved outcomes. But there is no mention of outcome analysis. This can not be done in a retrospective study. To do this you need to have two similar groups of patients, one who had a particular intervention and one who did not. Then you compare their outcomes using predetermined measures like death or LOS.

Retrospective studies are good for suggesting that an intervention may be doing something good. Then you study it prospectively to see if that suggestion was correct. In a retrospective study you have no control over who got the intervention and who didn't. Maybe you look at your registry and notice that in your penetrating chest trauma patients who had decreased or absent breath sounds on one side, the mortality rate for pts. getting NT was 10% and was 40% for the pts. not getting NT. The problem in drawing a causal relationship here is you don't know what else was going on in the two pt. groups. Also my registry wouldn't reliably capture the entry criteria of absent breath sounds.

I hope that helps.

R. Smith

 

From: Timothy Coats
Date: Tue 17/12/2002 18:49

This would seem like a good area for a pre-hospital RCT:
There is a lack of evidence. There is a body of expert opinion both for
and against the procedure (hence an argument could be made to a
ethical review board). There is a significant number of pre-hospital
providers already trained in the skill. Many institutions have a trauma
audit system that could be used to collect outcome data.

Still to be defined:
1) The exact question.
2) Precise inclusion / exclusion criteria.
3) Precise randomisation strategy.
4) Precise outcome measure.
5) Sample size calculation.

OK, it is unlikely that the research funding bodies will come up with
any money (as the genome is not involved - or maybe I am just bitter
and twisted!), but it would seem a good idea to have at least thought
about the protocol that might be used to resolve this discussion.

How about this as a three part question to start off:
"In patients with suspected tension pneumothorax does pre-hospital
needle chest decompression or no thoracic drainage give better
survival to 24 hours"

Tim.

PS. Can I add my anecdotes that individual patients can make
dramatic improvements after pre-hospital needle chest
decompression, but that diagnosis is very difficult.

I can well understand the frustration of the pre-hospital providers on
this list who seem to have recognised a dissonance between the
evidence base ("there is little or no evidence to support the use of pre-
hospital needle chest decompression") and their clinical experience
("but I've seen it have a dramatic effect"). However, the trauma
surgeon's anecdotal experience ("I've seen lots of complications from
pre-hospital thoracic draniage") should give the pre-hospital enthusiast
pause for thought.
How about this as an explanation for these different views:
Life threatening tension pneumothorax is pretty uncommon. Pre-
hospital diagnosis is difficult (noise etc) and much of the time the
diagnosis is incorrect. Once you have a skill there is a tendency to use
it. Needle chest drainage may or may not be effective. In the rare
situations where there actually is a tension pheunothorax it may give a
dramatic improvement (colouring the viewpoint of the pre-hsopital
provider). Most of the time the patient is either not helped (with an
Xray it is easy for the ER team to make a diagnosis) or a complication
is created (colouring the viewpoint of a thoracic surgeon).

 

From: Tim Coats
Date: Tue 17/12/2002 19:07

If they are awake and alert keep your hands in your pockets. I would
strongly disagree with your Instructors. This patient does not need a
needle chest decompression.

Tim.

PS: My anecdote of patient opinion - a young man fell 20 feet hitting
the right side of his chest on a metal bar just above the ground. On
our arrival at the scene: blue, chest hyperinflated, occasional
respiratory effort (probably about 6 a minute), unable to speak, eyes
rolled back with no visual contact, trachea deviated, bradycardia of
35 bpm. Right needle chest decompression gave immediate
improvement with normal saturation and blood pressure. Patient said
"Thank you doc" or "I thought I was going to die" with each breath all
the way to hospital.
(At this time, which was a few years ago, paramedics in the UK could
not perform needle decompression).
So I think that there are a subset of patients that benefit. Our
argument should really be revolving around whether or not it is
posisble to design a system that safely identifies that subset, and the
deficits in our current audit systems.
Tim.

From: John L Meade
Date: Tue 17/12/2002 20:06

About a 18 months ago, we were interested in just this sort of trial, to see if
needle decompression of suspected tension pneumothoraces by paramedics was a
provably good thing to do.

I contacted a colleague with the University of Florida in Jacksonville, Dr. Bill
Bozeman, who is active in both EMS and research, for his thoughts. Here is a
portion of his letter to me at that time.


JM

John L. Meade, MD, FACEP
Emergency Medicine Specialist
Emerald Healthcare Group, P.A.
http://www.statdoc.com/

______________________________________________________________________
Tension pneumothorax is primarily a complication of traumatic injury,
and is uncommon. In a prospective series, prehospital NT was performed for
suspected (simple) PTX in 1.7% of 6241 major trauma patients. (Eckstein,
Prehosp. Emerg Care 1998.) We can generously presume that all of these major
trauma patients had tension PTX. The complication rate noted in another report
was zero among 207 patients. (Barton, J Emerg Med, 1995.) Using the method of
Hanley et al for 95% confidence interval estimates with zero numerators (JAMA,
1983), the upper limit for the complication rate would be 1.4%. In our system,
an annual EMS volume of 63,000 patient runs yields approximately 1850 (2.9%)
major trauma patients.

Power calculations show that a prospective study with an 80% chance of
demonstrating a difference from zero (alpha = .05) in a group with a
complication rate of 1.4%, would need approximately 10,000 patients with the
condition of interest. This is similar to the sample sizes required in many
cardiology studies examining events of similar frequency. Based on the above
estimates this group of 10,000 patients with tension PTX would require 588,235
major trauma patients. This could be achieved with a prospective sample of 20.2
million EMS runs. A multicenter trial involving a large number of Level 1 trauma
centers would be the most practical approach to a study of this magnitude.
Significant funding would be needed.

Another approach to a related question would involve comparing outcomes
among two groups that did or did not receive NT. This approach to showing
efficacy would need fewer patients. However, there are several barriers to such
a trial. Given that NT decompression of tension PTX is recognized as standard of
care and a lifesaving intervention, it would be extremely difficult to justify a
comparative trial that included an arm that withheld NT. If at some point some
literature became available that questioned the efficacy or raised concerns of
risks that outweighed the lifesaving benefits of this intervention, then a
prospective comparative trial could be contemplated. As a resuscitation study
involving a vulnerable population that cannot give informed consent, such a
study would be subject to the federal regulations concerning waiver of informed
content and would require adherence to the stringent requirements of those
regulations. (See: Resuscitation research and emergency waiver of informed
consent. Resuscitation. 2000 Nov;47(3):307-10. ) Only a handful of trials have
successfully utilized this waiver thus far.

It seems that a prospective evaluation of the efficacy and complication
rates of NT would be prohibitively difficult and expensive at this time.
Although the currently available literature on prehospital NT is indeed limited,
it would not support withholding NT from patients with suspected tension PTX.
This would present a problem with justifying a comparative trial.

From: Eric Frykberg
Date: Tue 17/12/2002 21:34

Isn't it such a sad comment on some of the primitiveness that still pervades medicine
that we find ourselves in this position--an unproven modality that involves clear risk to the patient is introduced, then widely adopted without question like wildfire (of course because it all makes us feel like we're doing something, and makes so much sense!) to the point that you can't stop it with a Mac truck? Turning science on its head. MAST trousers, steroids for the least suspicion of spinal cord injury are just two other ludicrous examples--we are our own--and our patients'--worst enemies in some ways.

From: Tim Coats
Date: Wed 18/12/2002 09:07

> John Meade wrote:
> > About a 18 months ago, we were interested in just this sort of
> > trial, to see if needle decompression of suspected tension
> > pneumothoraces by paramedics was a provably good thing to do.
> >

You took away my punch line - my follow up post was going to be
the sample size calculation!!!!

> ERF wrote:
> Isn't it such a sad comment on some of the primitiveness that still
> pervades medicine that we find ourselves in this position--an unproven
> modality that involves clear risk to the patient is introduced, then
> widely adopted without question
> like wildfire (of course because it all makes us feel like we're
> doing
> something, and makes so much sense!) to the point that you can't stop
> it with a Mac truck? Turning science on its head. MAST trousers,
> steroids for the least suspicion of spinal cord injury are just two
> other ludicrous examples--we are our own--and our patients'--worst
> enemies in some ways. ERF
>

I would disagree (carefully and from a distance!) with your argument,
but not with your conclusions. Evidence Based Medicine is about
using the best evidence available. The art of medicine is about making
decisions based on insufficient evidence - we are doing this every day
(especially in emergency care) and a very humbling experience it is,
especially in retrospect!

I would not totally dismiss a procedure just because there have been
no studies. This is probably more to do with the lack of funding for
trauma research and the current 'ethical' regulations rather than a
reflection of the effectiveness of the intervention. There is little
evidence for pre-hospital needle decompression because the studies
have not been done. (This is lack of effective evidence rather than
evidence of lack of effect). At present the best evidence we have here
is anecdote.

The best current evidence (anecdotes) seems to show that there are
indeed a (very few) patients who might benefit from a pre-hospital
needle decompression, but that the procedure is currently overused
with attendent complications. It is uncertain whether the group of
patients who might benefit can be identified with sufficient accuracy in
the pre-hospital phase. The incidence and severity of complications is
unknown and the risk / benefit balance has not been established.

The UK has a system for regulating new surgical procedures (since
the scandal of the introduction of 'keyhole' surgery). It does not apply
to the application of an established procedure in a new environment,
but if it did I think that pre-hospital needle chest decompression by
paramedics would have been rated "Should only be used in the
context of a well designed clinical trial".

We should be ranting at the lack of investment in trauma and pre-
hospital care research rather than yelling at our colleagues who are
trying to make decisions based on insufficient evidence. So I end up
standing with you in front of the Mac truck (or British Leyland lorry),
but by a different route.

Tim

From: Eric Frykberg
Date: Wed 18/12/2002 13:44

This is not really true, but I do agree with your general drift. If available evidence of appropriate quality is not available to support an approach, then we must go to reasonable assumptions--meaning we then cannot use evidence-based medicine--EBM is NOT about using poor evidence if that is all there is--then we must be guided by the tenets of risk-benefit ratio and Primum non nocere. This is how many unfounded dogmas began in our practices--CPR in trauma, MAST, routine colostomy, bloodletting,etc--and when they began, they were reasonable things to do given the rationale and state-of-the-art of medicine at the time(i.e. in WWII there were no antibiotics, no mechanical ventilators, no critical care, etc to care for colon anastomoses that fell apary--at least a colostomy took away any risky suture line)-- The problem has been the evolution of these practices into entrenched dogma to the point we all forget how it started, and far beyond its appropriateness, simply because we are human beings who always look for the easiest road, and it is always easier to not think just do, "because that's what I was taught, and this is what so-and-so does, he is great, so it must be right". This is how the Dark Ages of western civilization lasted for 1000 years--Aristotle and Galen said something therefore that is the only right answer. This then evolved to being tortured into conformity if you dared question "Why"--nowadays we are a bit more sophisticated, but I hope everyone can look at the last 4 days of posts on CPR in trauma and see that we still have the witch doctor/shaman quality in all of us. Now those who question entrenched yet unfounded dogma--doing nothing more than pointing out there is no basis for the practice, and there is potential harm) are merely ostracized (like Ignaz Semmelweiss, to the point he became insane as he watched young women continue to drop like flies), or labeled with qualities like "bad manners", "abrasive", "jerk" etc.
Think about it
ERF

From: Peter Franklin
Date: Tue 17/12/2002 21:30

As an EMT i came across 5 cases of Tension Pneumothorax & all but one died.
Since graduating as a Paramedic i have only come across 3 cases & have successfully decompressed them with the patients making full recoveries.
You are quite right however that for the most part in the UK we are not subject to as severe a level of trauma as in SA & even in such cases,we are a crowded little island & most of us are never far from an ER.
This results in a lesser pre hosptial phase in which life threatening pneumothoraces can develop.

From: John L. Meade
Date: Wed 18/12/2002 20:31

Rick,

Help me here. Are you denying the existence of the entity “tension pneumothorax”, or the need for rapid decompression of TP, or the utility of rapid decompression of TP via needle (in favor of pleural tube drainage)?

I feel that some of the focus may have been lost. At least for myself. Help clarify the point being discussed, to the exclusion of others.

From: Eric Frykberg
Date: Wed 18/12/2002 22:55

John--
I went back and read my post and it still seems perfectly clear to me what I said--I was commenting on the poor to nonexistent quality of data being presented to justify doing this--now go back and look at the post I was responding to, and my answer--I guess I'm living on a different planet here. I was making the point that anecdotes are not evidence at all--you cannot make any conclusions, nor initiate any interventions, on the basis of undocumented "war stories" like this.

`I have been seeing trauma patients as the major part of my practice now for over 17 years in a Level I trauma center that sees over 4000 injured victims/year. I hope this gives some credence to what I say, that I am not just saying this stuff to hear myself.
Most other trauma surgeons on this list some more experienced than me will tell you the same thing--hell, HAVE BEEN telling you the same thing over and over. There may well have been a handful of patients at the edge of death from a tension pneumothorax in these years whose condition was improved by placing a needle in a chest, but I have yet to see such--it sounds sensible, doesn't it, that it should help, but this scenario is so rare it basically just does not happen any where near often enough to justify the indiscriminate use of these as does go on every day across our country. You cannot justify an invasive intervention that poses clear risk to the patient (a risk WE have to then clean up, mind you, as the perpetrators wash their hands and never have to bother with the patient again, ready to do the same thing again tomorrow) I get tired of seeing patients stuck and full of needles like pin cushions, with simple obviously iatrogenic PTX's that now I am going to have to clean up after by slogging hard work. As I said, a surprising number never even entered the chest--homeopathic Rx, I guess? Acupuncture?

Just a couple weeks ago, a 72 yo MVC victim on coumadin underwent such a needle into his LIVER!--after about 4 units of blood he should not have gotten, he fortunately stopped on his own . I read the run sheets on these stuck patients and see NORMAL vital signs in the field at the time of being stuck. Yes! Why were they stuck? You should hear some of the reasons, like "well, I thought there were diminished breath sounds". We don't know that in the absence of shock, there is no tension PTX? I don't really blame the prehospitalers always for this, as their medical directors often do encourage this--they too have nothing to lose and never see the patient again for their prolonged hospitalization. IF a patient is truly in extremis in the field, obviously close to arrest, I have no objection to trying this along with a few other things to keep alive, but there is no discrimination being shown out there! How could a paramedic with 12 years experience in the field who does not know when he is sticking the liver instead of the chest be allowed to make such decisions on his own--yet he continues to be able to!

The risk of this procedure AS IT IS BEING APPLIED OUT THERE far outweighs any documented benefits--as we have yet to see any documented benefit, only what "sounds reasonable--makes sense, etc"
Think about this--it also sounds reasonable that the sun rotates around the earth--look! You and I see this happen every day with our own eyes--how could you deny it? How silly to ask for "evidence"--we see this with our own eyes! Well, the evidence comes in, and gee--guess what? Same for MAST trousers--makes so much sense--we can see the BP come upi with our own eyes when inflated--how can you ask for "evidence" of its worth"? Well, gee--the evidence comes in and guess what?
Those who do not know history are condemned to repeat it---Santayana
Think about it
ERF

From: James A Johnson
Date: Thu 19/12/2002 21:25

While everyone likes to prove their point with data they should be treating
the patient if there is increase difficulty in resp. diminished or absence
of breath sounds on one side, hyperresence, cyanosis with no other
explanation this chest needs decompressed with a 10 gauge 2 1/2in. cath with
a hiemlich valve. while 14's and 16's will work you get the problem
mentioned below of the cath not entering the thorax.

From: Ken Mattox
Date: Fri 20/12/2002 01:02

Please, please, provide us with whatever evidence that this outlandish statement made by you, Dr. Johnson, has any, ANY, basis in FACT. Do you have any earthly idea how many patients you have created an iatrogenic systemic air embolism on with this kind of foolish statement and maneuver? Do you even know when and where and why this chest needle decompression can and does cause fatal iatrogenic systemic air embolism? If you answer is, "no, please tell me." then you need to give an apology to every reader of this web site that you have given bad advice.

k

From: Pret Bjorn
Date: Fri 20/12/2002 13:14

I'm not smart or confident enough to take sides on this thread yet, but I'll bite.

I've never seen (noted? appreciated?) a complication to a needle thoracostomy--unless one includes small pneumothoraces, which could rightly be described as either a complication or an indication, depending on which side of the intervention you're on, chronologically or physiologically.

Then again, the small handful of needle thoracostomies I've seen have been pretty much by the book: second ICS, over the third rib at the MCL, with a big, shallow IV catheter and some manner of flutter-valve. To my recollection, all were inserted in cases of cardiopulmonary extremis accompanied by some combination of absence of breath sounds, tracheal deviation, chest wall asymmetry, and/or JVD. And it's important to understand that these interventions aren't typically undertaken in our driveway: Maine's a blunt-trauma state, where it's occasionally a twenty-minute flight to indoor plumbing, much less the talent and wisdom of an esteemed thoracic surgeon.

Plus, it worked pretty well for Mark Wahlberg in Three Kings.

And so, specific to your second question, Ken: "No, please tell me."

Happy Holidays, and I hope this finds you in best of health.

Pret

From: Meredith McBride
Date: Fri 20/12/2002 13:39

I've seen two separate cases of persistent air leaks, one which required thoracoscopic evaluation/treatment. One was actually from a trocar introduced, anterior chest tube, performed in the ambulance en route, on a patient with BP 140 range (the EMT apparently thought the needle had not adequately restored 'breath sounds').

From: Thomas Anthony Horan
Date: Fri 30/08/2002 18:59

Pret,

as always it is a pleasure to read your reasonable statements. There has been much heat and little light generated in this thread. Some focus on the complications apparently caused by pre hospitalists while denying the possibility of benefit, they cite only their own anecdotal evidence while accusing others of interventions based on anecdotes. the literature contains little to help with the benefit of pre hospital intervention (see Dr Coats) below and no evidence whatever of the level of risk occasioned by needle decompression. We are left therefore only with the ex cathedra pronouncements of authorities eg. ATLS.

Tom Horan

TI: Pre-hospital management of patients with severe thoracic injury.
AU: Coats,-T-J; Wilson,-A-W; Xeropotamous,-N
AD: Helicopter Emergency Medical Service, Royal London Hospital, UK.
SO: Injury. 1995 Nov; 26(9): 581-5
IS: 0020-1383
PY: 1995
LA: English
CP: ENGLAND
AB: The physiological variables of oxygen saturation, blood pressure and pulse rate were compared in the pre-hospital phase and on arrival at hospital in a group of 63 patients with severe chest injury. Eighty-nine pre-hospital thoracic drainage procedures were carried out. Pre-hospital Advanced Trauma Life Support (ATLS) was associated with a significant improvement in all three variables. Median oxygen saturation increased by 17 per cent (P < 0.001), median blood pressure increased from 90 to 120 mmHg (P < 0.001) and median pulse rate decreased from 125 to 105 (P < 0.001). Pre-hospital intervention is indicated for tension pneumothorax, and contraindicated for haemothorax without respiratory compromise. In other situations further evidence is required, and standard ATLS protocols should be used until this is available.

From: Martin Fischmeister
Date: Sat 21/12/2002 20:39

It is probably worth to analyse situations more exactly. Tension pneumothorax comes in many different situations - as long as the patient is breathing spontaneously and the clinical picture allows I always wait for an x-ray. I have seen a patient walking through the door of the hospital and after the first examination we brought him to the shock-trauma area and after an x-ray he got a drain immediately. If you start intubation and positive pressure ventilation in the field or in the shock trauma area you can aggravate the situation (tension pneumothorax) in a few minutes time. Here you have to react immediately - if you do this by drainage or simple placing a cannula is of no great importance - but you should know that only a drain will solve the situation definitely. I have seen at least one patient being brought dead to the shock-trauma area, who died because of an unrelieved tension pneumothorax
but had been intubated and ventilated in the field.

Martin Fischmeister
Unfallkrankenhaus Linz Austria

From: Avi Roy Shapira
Date: Mon 23/12/2002 08:29

I think Tom summarized the issue quite nicely. It is difficult, if
impossible to prove benefit of needle decompression. If the patient
survives, detractors will say he/she would have survived anyway.

In his "Galapagos:, K Vaunegut Jr. writes that because of our big
brains, we find it hard to distinguish facts from mere opinion.

What we get here is mere opinion. Lots of it.

I suggest that the take home message from this discussion should be the
following:

1. Needle decompression can be associated with complications.
2. It should not be used lightly.
3. It should never be used just because we don't hear breath sounds on one
side.
BUT
4. In clear cut cases: shock with distended neck veins, reduced breath
sounds, deviated trachea, it could be life saving.

I think (opinion) that distended neck veins are key. If the patient has
distended neck veins he is surely not hypovolemic (fact). If in shock, it
must be pump failure. In blunt trauma, TP would acount for the
overwhelming majority of pump failures (fact), so add the reduced breath
sounds, and you clinch the diagnosis.

Please, Eric and Ken, correct me if I am wrong, but I believe that the
complications occur when the indications are iffy. The complications you
had witnessed, were they in patient with clear cut evidence of tension
pneumothorax?

Those complications that I have seen, and I have seen a few, were all in
cases where the indication ranged from questionable to non-existant. I
suspect that Eric's and Ken's objections are intended more to prevent
indiscriminate use rather than impose a total ban.

Like everything else in life, moderation is key. Even water can kill you
if you drink too much.

Avi

trauma.org (8:2) February 2003