Prehospital Pleural Decompression & Chest Tube Placement After Blunt Trauma

Wednesday, June 27, 2007

Review of: Waydhas C, Sauerland S: "Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review." Resuscitation. 72(1):11 25, 2007.

The Science

The authors of this paper attempted to answer the following questions related to the diagnosis and treatment of pneumothorax in the out-of-hospital setting. What are the diagnostic requirements and the accuracy for pneumothorac and tension pneumothorax? What are the indications for emergent pleural decompression? What is the best technique? And, is there a role for chest tube placement?

They ranked the studies and independently categorized the level of evidence from level 1 to 5, then graded it A (Level 1), B (Level 2 and 3), and C (Level 4 and 5). They make the following recommendations.

Grade A

1. A pneumo- or hemothorax can be assumed when ipsi-lateral breath sounds are diminishted or absent, provided the ET tube is correctly positioned.
2. Normal breath sounds, particularly in conjunction with a normal respiratory rate and no thoracic pain, rule out a large significant pneumothorax.

Grade B

1. Clinical examination should include respiratory rate and lung auscultation.
2. Needle decompression often appears to be an effective, easy to use, and relatively safe method to treat tension pneumothorax.
3. Surgical decompression of the pleura without chest tube placement appears to be an effective method of treating tension pneumothorax.
4. A needle length of at least 4.5 cm (1.8 inches) should be used for needle decompression.

Grade C

1. Clinical examination of the patient with suspected chest injury appears warranted.
2. Monitoring of airway pressure in intubated patients and pulse oximetry may be helpful.
3. Subcutaneous emphysema may indicate the presence of pneumothorax.
4. A tension pneumothorax should be suspected if recommendation A number 1 in combination with signs of respiratory distress, shock, increased airway pressure, and hyperexpansion of the chest.
5. A clinically suspected pneumothorax should be decompressed at the scene.
6. A clinically suspected pneumothorax can be decompressed in the ventilated patient, but the spontaneously breathing patient should wait until hospital arrival as long as close monitoring can be performed.
7. Both the 4th 6th intercostals space in the mid-axillary line or the 3rd intercostal space in the mid-clavicular line are suitable for needle decompression or chest tube insertion.
8. Placing a Heimlich valve on the end of the chest tube may be helpful in the spontaneously breathing patient. No recommendation is made for the ventilated patient.

The Street

This is a very interesting article, particularly when taken in context with the following statement from Dr. Ken Mattox at the Baylor College of Medicine. He said, "There is indeed a lot of emotion relating to the ability to perform a technical assault on a patient, including needle decompression in the field. I have found NO, I repeat NO, data which were prospectively collected in a randomized fashion which justifies this dangerous practice. I would strongly recommend that prehospital chest decompression by ANYONE by any method be eliminated until appropriate evidenced based data exist." While he made that statement 10 years ago, I suspect he still feels the same way.

Unfortunately, despite providing numerous and sometimes conflicting recommendations, the authors failed to answer the real question. "Is there a clearly defined role for needle decompression in EMS?" Furthermore, it must be noted that the authors are from Germany, and their perspective of the scope and practice of prehospital medicine may differ significantly from that of their American counterparts. And finally, it is difficult to accept the opinion of two authors in determining the level of evidence of the literature. Generally, large expert panels are required to come to consensus on the value of individual research result.

With all of this said, I hope this paper spurs further debate and research on this rarely used but potentially life-saving procedure.