trauma.org (8:2) February 2003
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
Date: Tue 17/12/2002 06:28
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.
Date: Tue 17/12/2002 11:38
Not that much evidence available, but have a look at the
following two references.
Needlethoracostomy in the prehospital
Eckstein M . Suyehara D .
Department of Emergency Medicine, University of Southern California
School of Medicine, Los Angeles 90033, USA. firstname.lastname@example.org
Prehospital Emergency Care. 2(2):132-5, 1998 Apr-Jun.
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.
Needlethoracostomy may not be indicated
in the trauma patient.
Cullinane DC . Morris JA Jr . Bass JG . Rutherford EJ .
Vanderbilt University Medical Center, Tennessee, Nashville,
Injury. 32(10):749-52, 2001 Dec.
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.
Date: Tue 17/12/2002 12:03
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.
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
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
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
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
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
in hospital you would sedate and place a chest tube, but in
prehospital setting with 10+ minutes to the hospital...
I don't suppose the patients who "had subjective improvement
dyspnea" might have said "OK, I feel better. Just
stop poking me in the
chest with those big needles."
PS I did not agree. They stated that I should not be allowed
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?
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
So, Dr. Frykberg, how does this show that "The proper
conclusion from this data would be that there appears to be
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.
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
Date: Tue 17/12/2002 19:03
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.
Date: Tue 17/12/2002 18:49
This would seem like a good area for a pre-hospital
There is a lack of evidence. There is a body of expert opinion
and against the procedure (hence an argument could be made
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
and twisted!), but it would seem a good idea to have at least
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
needle chest decompression or no thoracic drainage give better
survival to 24 hours"
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
this list who seem to have recognised a dissonance between
evidence base ("there is little or no evidence to support
the use of pre-
hospital needle chest decompression") and their clinical
("but I've seen it have a dramatic effect"). However,
surgeon's anecdotal experience ("I've seen lots of complications
pre-hospital thoracic draniage") should give the pre-hospital
pause for thought.
How about this as an explanation for these different views:
Life threatening tension pneumothorax is pretty uncommon.
hospital diagnosis is difficult (noise etc) and much of the
diagnosis is incorrect. Once you have a skill there is a tendency
it. Needle chest drainage may or may not be effective. In
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
Xray it is easy for the ER team to make a diagnosis) or a
is created (colouring the viewpoint of a thoracic surgeon).
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.
PS: My anecdote of patient opinion - a young man fell 20
the right side of his chest on a metal bar just above the
our arrival at the scene: blue, chest hyperinflated, occasional
respiratory effort (probably about 6 a minute), unable to
rolled back with no visual contact, trachea deviated, bradycardia
35 bpm. Right needle chest decompression gave immediate
improvement with normal saturation and blood pressure. Patient
"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
not perform needle decompression).
So I think that there are a subset of patients that benefit.
argument should really be revolving around whether or not
posisble to design a system that safely identifies that subset,
deficits in our current audit systems.
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.
John L. Meade, MD, FACEP
Emergency Medicine Specialist
Emerald Healthcare Group, P.A.
Tension pneumothorax is primarily a complication of traumatic
and is uncommon. In a prospective series, prehospital NT was
suspected (simple) PTX in 1.7% of 6241 major trauma patients.
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
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
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
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
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
Significant funding would be needed.
Another approach to a related question would involve comparing
among two groups that did or did not receive NT. This approach
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,
prospective comparative trial could be contemplated. As a
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
regulations. (See: Resuscitation research and emergency waiver
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
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
This would present a problem with justifying a comparative
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
> > 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
> pervades medicine that we find ourselves in this position--an
> modality that involves clear risk to the patient is introduced,
> widely adopted without question
> like wildfire (of course because it all makes us feel
> 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
> 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
using the best evidence available. The art of medicine is
decisions based on insufficient evidence - we are doing this
(especially in emergency care) and a very humbling experience
especially in retrospect!
I would not totally dismiss a procedure just because there
no studies. This is probably more to do with the lack of funding
trauma research and the current 'ethical' regulations rather
reflection of the effectiveness of the intervention. There
evidence for pre-hospital needle decompression because the
have not been done. (This is lack of effective evidence rather
evidence of lack of effect). At present the best evidence
we have here
The best current evidence (anecdotes) seems to show that
indeed a (very few) patients who might benefit from a pre-hospital
needle decompression, but that the procedure is currently
with attendent complications. It is uncertain whether the
patients who might benefit can be identified with sufficient
the pre-hospital phase. The incidence and severity of complications
unknown and the risk / benefit balance has not been established.
The UK has a system for regulating new surgical procedures
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
paramedics would have been rated "Should only be used
context of a well designed clinical trial".
We should be ranting at the lack of investment in trauma
hospital care research rather than yelling at our colleagues
trying to make decisions based on insufficient evidence. So
I end up
standing with you in front of the Mac truck (or British Leyland
but by a different route.
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"
Think about it
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.
Date: Wed 18/12/2002 20:31
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.
Date: Wed 18/12/2002 22:55
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
Those who do not know history are condemned to repeat it---Santayana
Think about it
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
of breath sounds on one side, hyperresence, cyanosis with
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
mentioned below of the cath not entering the thorax.
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.
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
Happy Holidays, and I hope this finds you in best of health.
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').
Date: Fri 30/08/2002 18:59
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.
TI: Pre-hospital management of patients with severe thoracic
AU: Coats,-T-J; Wilson,-A-W; Xeropotamous,-N
AD: Helicopter Emergency Medical Service, Royal London Hospital,
SO: Injury. 1995 Nov; 26(9): 581-5
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.
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
but had been intubated and ventilated in the field.
Unfallkrankenhaus Linz Austria
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
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
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
4. In clear cut cases: shock with distended neck veins, reduced
sounds, deviated trachea, it could be life saving.
I think (opinion) that distended neck veins are key. If the
distended neck veins he is surely not hypovolemic (fact).
If in shock, it
must be pump failure. In blunt trauma, TP would acount for
overwhelming majority of pump failures (fact), so add the
sounds, and you clinch the diagnosis.
Please, Eric and Ken, correct me if I am wrong, but I believe
complications occur when the indications are iffy. The complications
had witnessed, were they in patient with clear cut evidence
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.
suspect that Eric's and Ken's objections are intended more
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.
trauma.org (8:2) February