Vol. 7.1
1. Needle Decompression Complicated by Cardiac Injury in a Prehospital Environment. Davis KA, Oury JJ, Reed BL, Grabo D, Wilson A, Coleman G. J Spec Oper Med. 2024;24:78-80.
2. Comparison of out of hospital finger and needle thoracostomy performed by ground emergency medical services. Ciaraglia A, Smith A. Axtman B, et al. International J Paramedicine, 2024;(6), 9–16. Full text available online at: https://internationaljournalofparamedicine.com/index.php/ijop/article/view/2820/2778
3. Outcomes of adult patients discharged at scene by emergency medical services. Villani M, Nehme E, Cox S, Anderson D, Reinders N, Nehme A. Emerg Med J 2024;41:459–467
4. Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war. Butler F, Holcomb JB, Dorlac W, et al. J Trauma Acute Care Surg. 2024;97: S45–S54.
International Prehospital Medicine Institute Literature Review, August 2024
1. Needle Decompression Complicated by Cardiac Injury in a Prehospital Environment. Davis KA, Oury JJ, Reed BL, Grabo D, Wilson A, Coleman G. J Spec Oper Med. 2024;24:78-80.
Tension pneumothorax has long been recognized as a preventable cause of death, both on the battlefield and in civilian emergency care. A tension pneumothorax can occur as a result of trauma, both penetrating and blunt, to the thorax. This trauma results in an increasing entrapment of air within the pleural space causing increased pressure in the involved hemithorax and compression of the great vessels of the chest and heart. The resulting loss of perfusion yields shock states that quickly lead to death if the pressure within the pleural space is not reduced. The most common way to relief the pressure is to blindly insert a needle into the pleural space allowing trapped air to escape. Most prehospital providers can easily repeat the mantra for needle decompression; “A 3.25 inch, 10 – 14-gauge needle inserted at the 2nd or 3rd intercostal space mid clavicular line or 4th or 5th anterior axillary line”. Prehospital medicine courses such as Tactical Combat Casualty Care frequently teach this procedure on a manikin with the needle being inserted to the hub.
The authors of this case study describe a scenario where tension pneumothorax was first misdiagnosed and the attempted needle decompression resulted in the needle being placed into the patient’s heart and through the intraventricular septum.
The patient was an adult male who arrived at the emergency department via helicopter EMS. The patient presented with multiple stab wounds to his thorax and left leg. For unknown reasons, the mid-level provider caring for the patient determined that he had a tension pneumothorax. In an attempt to relieve the presumed tension pneumothorax, the provider placed a 14-gauge IV catheter at the 4th intercostal space just to the left of the parasternal line. Blood was observed to be pulsating from the needle. Providers then clamped the IV catheter to stop the pulsatile flow of blood and the patient was transferred to an ACS verified Level 1 adult trauma center.
The patient’s exam at the trauma center was described as awake and alert, with no shortness of breath and with equal breath sounds. Stab wounds to the left flank, left thigh and posterior left thorax were observed. There was also an IV catheter in the left chest at the sternal border. The right chest and rest of the physical exam was unremarkable. The patient received an urgent tube thoracostomy to the left chest, with placement verified by X-ray and additional analgesia was administered. A computed tomography angiography revealed that the IV catheter in the left chest had traversed the right ventricle of the patient’s heart and the interventricular septum with the distal tip of the catheter resting in the patient’s left ventricle.
The patient was immediately taken to the operating theatre for successful removal of the IV catheter and closure of the penetrating wounds to the patient’s heart via sutures. Exploratory surgery of the left lung and pleural space did not reveal any injuries from the initial penetrating insult from the stab wounds. The patient subsequently went to the Intensive Care Unit and was discharged to home after 6 days in the hospital.
This case study demonstrates multiple teaching points. Every patient should have a comprehensive and organized physical exam including vital signs. Not all penetrating or blunt trauma injuries to the thorax result in a tension pneumothorax. Pneumothorax without tension generally does not need to be emergently reduced. Needle decompression is not a benign procedure. Proper needle placement for decompression is crucial for patient safety. A needle for chest decompression should not be placed medial to the nipple line. In both training and during patient care, needle decompression needles should not be “buried to the hub”. Providers should be trained to insert the needle during chest decompression until air can be heard escaping or relevant signs of decompression are realized. Once successfully into the pleural space the provider should stop inserting the metal needle and advance the soft catheter off the needle into the pleural space. Complications of misplaced decompression needles, in addition to cardiac injury as in this case, include penetration of the great vessels, spleen, liver and other upper abdominal organs.
Needle chest decompression can be a lifesaving intervention for patients with tension pneumothorax. Providers should always ensure that this is the correct procedure for the correct patient with the correct signs and symptoms before attempting needle decompression. They should also be well versed in the landmarks for the correct location for the procedure and be well practiced in performing needle decompression of tension pneumothorax.
2. Comparison of out of hospital finger and needle thoracostomy performed by ground emergency medical services. Ciaraglia A, Smith A. Axtman B, et al. International J Paramedicine, 2024;(6), 9–16. Full text available online at: https://internationaljournalofparamedicine.com/index.php/ijop/article/view/2820/2778
Tension pneumothorax (PTX) is a life-threatening injury pattern with a high mortality rate if left untreated. It is also recognized as an injury which is treatable if recognized early. Traditionally, needle thoracostomy (NT) is the method used by many prehospital providers to decompress a tension PTX. Performing a NT is not without risk as iatrogenic injury may occur to the heart, great vessels, lung or upper abdominal organs. Additionally a significant number of NT’s are unsuccessful as the needle does not actually enter the thoracic cavity. Despite these concerns, performance of NT by EMS providers is increasing in many prehospital services. The Tactical Combat Casualty Care (TCCC) guidelines recommend early NT for treatment of suspected tension PTX based on a mechanism of chest trauma and signs of respiratory compromise. More recently, performance of finger thoracostomy (FT) by EMS personnel is becoming an accepted alternative to NT. The authors of this study hypothesize that prehospital FT will be associated with an increased rate of intrathoracic decompression without a delay in transport to definitive care.
This was a retrospective study conducted in San Antonio, Texas of all patients transported to a Level 1 trauma center during a four-year period. Training for NT was done in accordance with national guidelines and the Advanced Trauma Life Support (ATLS) course. Training for performing FT was done by the individual EMS agencies. Indications of thoracic decompression were based on recommendations from the regional emergency response agency, the South Texas Regional Advisory Council (STRAC). Anatomical location for NT was at the discretion of the EMS provider and was either the 4th/5th intercostal space at the anterior axillary line or the 2nd intercostal space in the mid axillary line. A combination of urban and rural EMS providers were trained in the procedures. Thoracic decompression was defined as clinical documentation of EMS providers of a rush of air or fluid upon placement of the catheter or a rush of air/blood upon insertion of a gloved finger after FT.
A total of 34 patients met study criteria, of which 15 (44%) underwent FT and 19 (56%) underwent NT alone. Of the 15 patients receiving FT, 6 had a prior unsuccessful attempt at NT. The groups were well matched in terms of demographics and injury characteristics. No difference in transport times were observed. All patients in the FT group were in cardiac arrest prior to arrival, with 20% receiving return of spontaneous circulation (ROSC), while 6 of 19 NT patients arrived in cardiac arrest, with 66.7% achieving ROSC. The rate of successful decompression was higher in the FT group (93% vs 47%, p<0.001). The authors report a higher rate of chest tube placement in the NT group. Overall, in-hospital mortality was not statistically different between the groups.
There are several limitations to this study. This is a small, retrospective cohort of patients so drawing broad conclusions from this study is not practical. All subjects who received FT were in cardiac arrest, whereas only 6/19 in the NT group were in cardiac arrest, suggesting the FT cohort was more severely injured. They note a higher rate of chest tube placement in the NT group, likely due to this difference in severity of injury. In most centers routine chest tube placement for NT is not always indicated, as proper intra-thoracic placement of the catheter does not always occur. Every patient who receives a prehospital FT and arrives to the hospital alive is mandated to receive a chest tube. This study is also underpowered to detect complications from NT placement, such as subclavian, lung, and cardiac injuries from the needle.
This study compares FT and NT in patients with severe chest trauma and traumatic cardiac arrest. It is too small to change practice and some of the conclusions are not reflective of real-world practice (such as comparing rates of future chest tube placement among groups). It is a good first step in demonstrating the practicality of prehospital FT but further studies are needed before this practice should be considered safe and routine.
3. Outcomes of adult patients discharged at scene by emergency medical services. Villani M, Nehme E, Cox S, Anderson D, Reinders N, Nehme A. Emerg Med J 2024;41:459–467
For many years, patient refusals and non-transports have been part of routine Emergency Medical Services (EMS) protocols. These scenarios, whether initiated by the patient or the provider, help prevent the overuse of EMS and Emergency Department resources, but they are not without potential downsides.
The authors of this retrospective cohort study investigated patients who had paramedic-initiated release at the scene, were not transported after the initial 911 call, and who later recontacted EMS or visited the Emergency Department. The study focused on adult patients (18 years or older) who were discharged at the scene by paramedics in Victoria, Australia, between January 1, 2015, and June 30, 2019. In this study, recontacting EMS was defined as making an emergency call within 72 hours of the initial event. Hospital admission was defined as an overnight stay. A serious adverse event was defined as death, cardiac arrest, a triage category 1 (resuscitation) presentation at an ED, or admission to an intensive care unit or coronary care unit within 72 hours of the initial non-transport episode.
During the study period, there were 2,857,760 EMS calls. Of these, 21,789 were excluded for missing data and 375,758 adults were discharged at the scene following EMS attendance, with 222,571 (59.2%) being paramedic-initiated decisions. Among these cases of paramedic-initiated non-transport, 15,213 (6.8%) recontacted EMS, 11,179 (5.0%) presented to the ED, 5,352 (2.4%) were admitted to the hospital, and 577 (0.3%) experienced a serious adverse event within 72 hours. The likelihood within 72 hours of a hospital admission or serious adverse event was associated with increasing age of the patient and an abnormal vital sign.
The authors acknowledged a limitation of the study that the data was collected before the COVID-19 pandemic. They hypothesize that changes in healthcare-seeking behaviors and healthcare delivery, including the increased use of telehealth, might impact future findings.
The authors concluded that “our results show generally safe paramedic decision-making, with low occurrences of EMS recontact, ED presentation, hospital admission, and serious adverse events in patients with paramedic-initiated scene discharge.” However, the fact that 577 patients experienced serious adverse events within three days raises questions, particularly since an abnormal vital sign was noted as being associated with this issue. Although the total number of these patients was small, it suggests that any patient with an abnormal vital sign should be transported and not released. Unfortunately, the study did not explore the ultimate outcomes of those who were hospitalized or suffered significant events after being discharged by paramedics. Further investigation is needed to better understand the relationship between patient outcomes and paramedic-initiated field discharge.
4. Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war. Butler F, Holcomb JB, Dorlac W, et al. J Trauma Acute Care Surg. 2024;97: S45–S54.
Since the recommendation of the Tactical Combat Casualty Care (TCCC) committee calling for aggressive use of tourniquets on extremity hemorrhage, they have been used with success and relatively few complications in both the military and civilian settings. This paper reviewed the use of tourniquets by the Military in Afghanistan and Iraq, by civilians in the US and in the current Russo-Ukrainian war.
There has been great success in controlling bleeding using tourniquets in Iraq, Afghanistan and with use by civilians in the US with minimal complications. However there are a number of reports from the US civilian sector where tourniquets were applied when not medically needed. This has been observed in both EMS and non-EMS first responder tourniquet applications. In these situations tourniquets that were not medically indicated were removed on evaluation at the trauma center. Given the usually short transport times, these applications did not result in an increased risk of limb amputation.
In the Ukraine conflict, non-medically indicated tourniquets are a common occurrence. In one report, 75% of tourniquets evaluated were not medically indicated. While US Military and civilian operations had relatively short prehospital times, this was not often the case in Ukrainian operations where the lack of air cover meant evacuation was often delayed until they were afforded the cover of darkness and by ground with a mean time of 21 hours in one report. As would be expected, complications increase markedly with longer transport times. Examples of Ukrainian patients include one who had a tourniquet applied on an extremity with no wound and another with no clear vascular injury with a tourniquet in place for over 10 hours requiring amputation of the leg. On this case there was no record of the tourniquet ever being re-assessed until reaching the treating facility. These long evacuation times have been reported to be the cause of many amputations because of ischemia related to long tourniquet placement and prolonged tourniquet application syndrome (PTAS) with kidney injury requiring hemodialysis. In one article, tourniquet usage by Ukrainian forces between 2014 and 2022 revealed 2,496 casualties with limb injuries that had tourniquets applied. The duration of tourniquet application ranged from 50 to 380 minutes with a mean time of 205.9 minutes. There were 92 (3.7%) limb amputations in this group over the years looked at mainly due to extensive necrosis. The tourniquets were in place for 210 to 380 minutes among the patients that had amputations and 78 of the amputations had tourniquets in place for more than 6 hours.
The TCCC guidelines were changed in 2015 following a leg amputation in a patient with an 8 hour tourniquet application time. They called for a reassessment of applied tourniquets as soon as feasible but no longer than two hours after the tourniquet is applied. These guidelines called for the tourniquet to be removed if it was determined that the bleeding was minor or minimal. If the bleeding continues to present a potential life threat, conversion to other means of hemorrhage control using direct pressure and/or hemostatic dressings. Frequent reassessment for recurrence of the bleeding should be done.
This Multidisciplinary and Multinational Review of current Tourniquet use in the Russo-Ukrainian War made the following recommendations that apply to all settings, not just military, in which tourniquets are used:
1. Tourniquets are lifesaving and should be used aggressively in the presence of life-threatening extremity bleeding.
2. In wounded extremities with only minimal or minor bleeding, tourniquets are not needed and a simple dressing will suffice.
3. The application of a tourniquet when it is not medically indicated and when evacuation of the casualty is prolonged places the casualty at unnecessary risk of limb amputation and potentially life-threatening PTAS.
4. Reassessment of the need for a tourniquet on an injured extremity should be performed as soon as feasible but not later than 2 hours after tourniquet placement.
5. Early reassessment enables tourniquets that are found to be indicated to be moved to a location just proximal to the bleeding site, thus reducing both the amount of extremity tissue at risk of ischemic damage and the magnitude of PTAS that may be sustained if transport to surgical care is delayed or prolonged.
6. If the bleeding is judged to be potentially life-threatening in a delayed evacuation setting, convert the tourniquet to other means of bleeding control, such as hemostatic dressings applied with direct pressure as soon as feasible. If attempted conversion of the tourniquet is not successful at controlling the bleeding, reapply the tourniquet.
7. Current prehospital trauma training programs place insufficient emphasis on not using tourniquets for extremities with only minor bleeding and removing previously applied tourniquets when they are reassessed and found not to be medically indicated. This aspect of training should be reinforced.
8. Training on how to distinguish life-threatening extremity bleeding from bleeding that is minimal or minor should be received by all persons who might be called upon to manage casualties with applied tourniquets.
In their conclusion, the authors stressed the importance of training to emphasize avoiding leaving tourniquets in place that are not medically indicated. This training should be included across all layers of first response from citizen responders to military and EMS providers and on to the medical teams that receive these patients.
