Trauma is the leading cause of death for ages 1–44 years old and is the third leading cause of death overall, across all age groups.1 Chest injuries are directly responsible for more than 20% of all traumatic deaths (independent of mechanism) and account for 16,000 deaths annually in the United States.2 Of prehospital trauma calls, tension pneumothorax accounts for 0.2–1.7% and is a well-known cause of preventable mortality in these patients,3,4 even though a majority of thoracic injuries can be managed without surgery.5 In fact, only 10–20% of patients with chest trauma require operative intervention.6
The major symptoms of chest injury include, but are not limited to, shortness of breath and chest pain. The exact etiology of the underlying cause of these symptoms may be elusive on primary survey, and unrecognized chest injuries can impair the ventilating or oxygen exchange systems and lead to dire outcomes.
Needle thoracostomy, by the anterior approach, is currently the preferred emergent EMS chest decompression procedure to manage this potentially fatal process.
After review of the current literature, clinical guideline development, education, skills training, outcome measurement, quality review and physician leadership, we conclude that in the prehospital setting, simple thoracostomy is a feasible, safe, effective solution for tension pneumothorax causing subsequent traumatic cardiac arrest.7 This article discusses the development and deployment of a simple thoracostomy procedure as a safe method for extensively trained paramedics to resolve the potentially life-threatening condition of tension pneumothorax and associated traumatic cardiac arrest.
Pneumothorax is the progressive buildup of air within the pleural space, usually due to lung laceration that allows air to escape into the pleural space and become trapped. Positive-pressure ventilation will exacerbate this condition via the one-way valve effect phenomenon. As air continues to accumulate and pressure builds within the pleural space, tension is developed that pushes the mediastinum to the unaffected side. This causes displacement of the heart and trachea and collapses the superior and inferior vena cava. The result is occlusion of venous return to the heart and a subsequent decrease in cardiac output.
The clinical signs and symptoms of tension pneumothorax include dyspnea, anxiety, tachypnea, subcutaneous emphysema, absent breath sounds, hyperresonance on percussion of the chest, distended neck veins and possible tracheal deviation away from the affected side. It’s important to remember that tracheal deviation is generally a radiological finding on chest X-ray. Tracheal deviation primarily occurs in the intrathoracic space; generally when it’s found in the cervical trachea, it’s a perimortem or postmortem sign.
Without the aid of X-ray in the prehospital environment, first responders are dependent on accurate physical examination skills for the detection of tension pneumothorax.8 Prehospital providers must be vigilant in watching for cardiopulmonary findings associated with tension pneumothorax because the classic physical findings occur late in the disease process.
Management of tension pneumothorax typically involves reducing the pressure in the pleural space by emergent chest decompression with needle thoracostomy. A 14-gauge or 16-gauge catheter is inserted into the affected pleural space at the second intercostal space in the midclavicular line. The catheter should be inserted just above the third rib to avoid the nerve, artery and vein that lie just beneath each rib. The catheter is advanced its entire length, followed by needle removal, thus leaving the plastic catheter as a conduit into the pleural space. This allows the air trapped in the space to be released or aspirated. A one-way valve can be attached or a valve can be made from a finger of a sterile glove. The maneuver effectively relieves the pressure and converts a tension pneumothorax into a simple pneumothorax.
Making the Case for Change
Although much evidence in current literature reveals ominous outcomes for traumatic cardiac arrest in the field, this situation isn’t hopeless until all reversible causes of traumatic cardiac arrest are ruled out. Data regarding survival rates for traumatic cardiac arrest are based on cases when definitive management with tube thoracostomy and pericardiocentesis are performed in the ED. Because we don’t have many data points in close proximity in time to the point of injury, we must remain hopeful that moving definitive intervention to the field may generate more favorable outcomes.
To address this concern, the Montgomery County (Texas) Hospital District (MCHD) developed a strategy to manage traumatic cardiac arrest with associated chest trauma in the prehospital setting in 2010. The “three hole punch technique” involved the placement of bilateral needle thoracostmies and a blind pericardiocentesis in patients with chest trauma as a contributor to cardiac arrest. Although this technique proved relatively easy and useful, there were growing concerns regarding the needle thoracostomy technique.
Prehospital needle thoracostomy differs significantly from system to system. Most commonly, 14–16 gauge needles are used with lengths ranging from 3.2–4.4 cm with an associated failure rate ranging from 50–65%.8,9 Advanced Trauma Life Support (ATLS) guidelines developed by the American College of Surgeons specify the use of a 5-cm 14-gauge catheter in the second intercostal space at the midclavicular line for needle decompression. However, it’s reported that when utilizing a 5-cm catheter for anterior needle thoracostomy, based on computed tomography, the expected failure rate is 42.5%.10 The advent of longer catheters has alleviated much of the concern regarding under-penetration, but this has simultaneously created increased concern for over-penetration. Unfortunately, increasing the length of the needles used to perform chest decompression can result in iatrogenic injury to the lung, subclavian vessels, heart and great vessels.11
When the needle is inserted to relieve a tension pneumothorax and no rush of air is heard, it’s impossible to deduct whether this is due to no tension pneumothorax being present, improper placement, kinking or plugging of the catheter, or if the tension pneumothorax is localized or loculated.12 A tension pneumothorax that was initially relieved may also re-accumulate undetected as a result of catheter kinking or plugging.
To avoid the complications associated with needle decompression, a number of services in Europe have adopted simple thoracostomy as an option for chest decompression. Simple thoracostomy is a technique similar to the placement of a chest tube, traditionally done in the ED. It utilizes an incision with a scalpel and penetration directly into the thoracic cavity with forceps and a gloved finger to relieve the tension pneumothorax. The only major difference is that the chest tube isn’t inserted.
A two-year prospective observational study of all severe trauma patients transported by a regional helicopter EMS service in Italy examined 55 patients who underwent simple thoracostomy (51 unilateral and four bilateral) after experiencing blunt chest trauma. A pneumothorax or hemopneumothorax was found in 91.5% of performed procedures and a hemothorax in 5.1%. No cases of major bleeding, lung laceration or pleural infection associated with the simple thoracostomy procedure were reported, and no reaccumulation of the pneumothorax was reported after simple thoracostomy was performed. If reaccumulation of the pneumothorax was suspected, a finger sweep was performed. Authors of the study made it clear that only highly trained crews should perform this procedure.7
In 2009, a group of British researchers reviewed their air ambulance database across a 39-month period, finding 61 patients where prehospital traumatic cardiac arrest was identified. Of these, 37 patients received resuscitation attempts, with 18 undergoing chest decompression. In 17 of these patients, a simple thoracostomy was performed and one patient had needle decompression. Chest decompression was more likely to be performed by physician-led vs. double paramedic crews (61% [17/28] vs. 11% [1/9]; p = 0.01). No complications with the procedure were recorded, and return of spontaneous circulation was achieved in four patients who later expired; however, their deaths were attributed to head injuries and not traumatic injuries to the chest.13
In an age when EMS is now a physician medical subspecialty, medical directors are compelled to move out of the “cowboy days” and enter an era where they recognize and respect the standard of care. They must also realize when they’re advancing beyond that standard and engage the medical community in discussions about protocol development.
Those of us spearheading MCHD’s prehospital simple thoracostomy procedure recognized we had to get buy-in from stakeholders and potential critics. Prior to initiation, we discussed the concept, training program and clinical guidelines with our receiving trauma centers, EDs, trauma surgery services, and even other EMS services in the region. We also asked for feedback and if moving from needle to simple thoracostomy was a reasonable extension of the current standard of care.
A major concern of receiving hospitals was risks for both the patient and provider. However, there’s no risk to patients because this procedure is only used when all other care would be futile and resuscitation efforts are withheld or terminated. The only significant risk was of potential injury to the paramedic, either caused by using the scalpel or injuring the finger with fragmented bones or other debris upon insertion into the chest. Because of this, the procedure is optional for those at the appropriate clinical level and is an individually credentialed skill.
Consensus approval from the stakeholders, earned by creating an open dialogue in the community, allowed us to move forward with implementation.
The MCHD simple thoracostomy clinical guidelines were developed based upon London’s Air Ambulance protocol and provided research. Due to the novelty of this procedure by ground EMS units, we chose to utilize the technique solely in patients suffering from traumatic cardiac arrest with clear indications and contraindications. The procedure is not used in any other clinical scenario at this time.
Simple thoracostomy indications: Simple thoracostomy may only be performed on patients with traumatic cardiac arrest with known or suspected injury to the chest and/or abdomen.
Simple thoracostomy contraindications: Simple thoracostomy is not to be performed on patients who:
- Have cardiac output or blood pressure;
- Suffered devastating head trauma;
- Have blunt thoracic trauma with no witnessed cardiac activity; or
- Have loss of cardiac output for greater than 10 minutes.
The rational is that loss of cardiac output greater than 10 minutes and loss of neurologic function are associated with definitive mortality.14
Description of procedure: Place the patient supine with the arm on the affected side abducted and externally rotated with palm of the hand behind the patient’s head if possible. The paramedic must be positioned on the affected side, perpendicular to the patient. The site should be cleansed and, using a scalpel, a 1–2-inch incision is made between the fourth and fifth intercostal space at the midaxillary line over the rib. Usually this will be above the nipple line (males) and breast tissue should be lifted out of the way of the incision (females).
The scalpel is used for the skin only, followed by the use of blunt dissection with a large, curved clamp in a caudal direction. Following rapid blunt dissection, the curved clamp, in a controlled fashion, is used to pass through the intercostal muscles and penetrate into the pleural space. With the curved tips remaining just inside the pleural space, the clamp is opened widely to allow the expulsion of air and blood and subsequently pulled out. The ostomy through the intercostal muscles should allow free insertion of a finger without pushing and should be large enough to prevent re-tension from occurring.
A finger is inserted through the ostomy site and into the pleural space. Once in the pleural space, palpation of the parietal pleura and lung with the finger is necessary to ensure you’ve entered the thoracic cavity and that the possible tension pneumothorax causing the traumatic cardiac arrest has been managed. Confirmation of entry is also essential to ensure you haven’t entered subcutaneous fat. This technique also gives indisputable confirmation that you’re in the right place. This is an important difference to needle decompression, which doesn’t give indisputable confirmation of appropriate positioning nor an intact conduit to the space in the prehospital setting.
An occlusive dressing is then utilized to cover the wound. Each wound is circled with a permanent marker and labeled “EMS–L” (left) or “EMS–R” (right). This identifies incisions made by EMS in the event of autopsy or criminal investigation.
Training & Deployment
After development of the clinical guidelines, the department of clinical services (DCS) at MCHD developed a training program and deployment and outcome measurement strategies. The training takes place at Baylor College of Medicine’s Experimental Surgery and Surgical Training Laboratory. The educational component of the procedure, led by direct physician oversight, consists of three parts.
The first component is four hours of didactics covering the indications, contraindications, complications, equipment familiarization, positioning, technique and precautions of the procedure.
The second component is hands on, where MCHD paramedics perform a simple thoracostomy on an anesthetized swine model with direct physician supervision in a step-by-step fashion.
The third and final phase of training is scenario-based application of the procedure on the anesthetized swine.
Ongoing training is required twice a year in the anesthetized swine lab in order to maintain credentialing. It’s critical when introducing a high-risk, low-frequency, novel technique to ensure the service is financially committed to appropriate initial and continuing education as well as 100% quality review. Skill dilution is an important consideration, as well as both financial and practical considerations, which is why MCHD chose to train only supervisors and senior-level paramedics. Currently, 30 paramedics—approximately 10% of paramedics in the countywide system—have received this training.
System deployment included developing kits (required supplies, sterilization of specific items, and logistics) with MCHD’s Materials Management Department, which stocks and maintains inventory on units. Simple thoracostomy kits are located, stored and inventoried on each EMS vehicle, and each kit includes:
- Two pairs of sterile gloves, size 7.5/8;
- Two packages of ChloraPrep, 3 mL;
- One #11 disposable scalpel;
- Curved forceps;
- Two Tegaderm medical dressings; and
- One Sharpie permanent marker.
Quality Assurance & Improvement
The final step in the development of the initiation of the simple thoracostomy procedure included tracking, documenting and reviewing clinical and operational quality review data elements. Currently the goal is 100% case review from initial EMS contact to final case disposition. To accomplish this, ZOLL ePCR interventions were created and are now tracked and reviewed by the MCHD trauma coordinator and medical director for appropriate indications, contraindications, complications and adverse events.
Follow-up on each case is managed by the DCS trauma coordinator, who collects information from the EMS record, hospital record, and autopsy report in cases of death to prepare the case file for review. All cases are reviewed by the EMS medical directors followed by a case review meeting performed with the EMS crew and supervisor. There have been no adverse events or paramedic injuries associated with this procedure to date.
Simple thoracostomy in our system has been developed as a safe method for extensively trained paramedics to resolve the potentially life-threatening condition of tension pneumothorax and associated traumatic cardiac arrest. Effective deployment of this procedure in an EMS service is dependent on stakeholder buy-in, appropriate training, frequent retraining, and 100% quality review. In the future, we’ll publish the result(s) from our research-developed protocol, training, deployment and quality review.
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