shows: Finger Thoracostomy Vs Chest Tube Insertion Vs Needle - - PowerPoint PPT Presentation

What the evidence shows: Finger Thoracostomy Vs Chest Tube Insertion Vs Needle Decompression

Cynthia Griffin D.O., EMT-P University of Wisconsin MedFlight Fellow 2014 April 21, 2015

Objectives

• Review a quick history of trauma chest

decompression

• Review the procedure, pathophysiology, &

complications that can occur with needle thoracostomy (NT) while reviewing the literature

• Discuss if NT mandates tube thoracostomy (TT)
• Review the prehospital literature on NT vs TT
• Review the simple thoracostomy (ST) procedure

and the literature behind this

• Discussion and Questions

• M. Fitzgerald et al. Injury, Int. J. Care Injured (2008) 39, 9—20

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

German Study N=54 N=51

N=111 N=110 N=1

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

Possible Positions of Needle Thoracocentesis

M Fitzgerald , Injury, Int. J. Care Injured (2008) 39, 9—20

Injury, Int. J. Care Injured (2008) 39, 9—20 Emerg Med J (2005);22:788 N=25

http://3.bp.blogspot.com/-D7PpDFIofPc/VLT_ikG0v- I/AAAAAAAAJTM/ERLVw5aSsCk/s1600/intercostal_space.jpg

N=75

“Generally safe and rapid procedure” N=114

39 was 0.2% of their calls

“Judicious decompression prior to definitive care in the ED is a potentially life saving maneuver in the paramedics armamentarium”

N=39

Injury, Int. J. Care Injured (2008) 39, 9—20

Now, lets take a look at Chest Tubes…

Picture courtesy

• f Mr Ian Civil

Picture courtesy of Mr Adrian Pick

Injury, Int. J. Care Injured (2008) 39, 9—20

N=1

N=51

“78% w neg CXR initially s/p NT developed PTX of which 2 were tPTX”

“The laws of physics dictate that the clinician should consider PTX expansion as a risk assoc. w intratransport ascent and decreasing ambient pressure”

N=66

belly

“With proper technique we consider pre-hospital TT to be a safe technique for the Rx of suspected tPTX w/out increased risk of iatrogenic injury.”

N=76

“There was no significant difference in the rate of malposition in the on scene vs in hospital placed chest tubes”

N = 24scene, 77 ED

“NT generally safe and rapid rx for tPTX in field TT should be adjunctive if NT fails & can be performed w out complications or worsening outcomes” “TT was associated with less DOA, than NT”

N=106 TT, 169 NT

“Aeromedical crews appear to appropriately select MTVs to undergo field NT or TT. “

N = 136

“Swine model of thoracic insufflation showed NT w High failure rate for relief of tension physiology & for Rx of the tPTX induced PEA which was due to both mechanical failure & inadequate evacuation.”

N=40

“Prehospital use of TT by qualified professionals does not introduce additional risks of complications compared w/in Hosp therefore is a lifesaving & valuable addition to prehospital care.”

N > 162

• TT on scene vs ED
• “There appeared to be no differences

between chest tubes inserted in the emergency room or at the scene”

• Beware of the complications with TT ~13

http://www.trauma.org/archive/thoracic/images/chestdrain01.jpg

http://www.trauma.org/archive/thoracic/CHESTdrain.html

N=45

“Demonstrated ST to be a safe & effective method of chest drainage without major complications or infections related to field

• thoracostomy. Moreover,

no recurrent tension PNX

• ccurred”

N=55

“Finger Thoracostomy” 10-30-2013

Summary of Recommendations

• Not all rushes of air means NT

is successful.

• NT has limitations although

may be used as a temporizing measure.

• Decompression with

breaching the pleural space is definitive treatment for tPTX.

• Giving them the finger with

ST has data supporting this as effective and safe.

References

• Biewener A, Aschenbrenner U, Rammelt S, Grass R, Zwipp H. Impact of helicopter transport and hospital level on mortality of polytrauma patients. J Trauma 2004; 56:94–98.
• Delooz HH. Training manual: emergency medicine residency. Leuven, Belgium: University Department of Emergency Medicine; 1991. [Context Link]
• Fitzgerald M et al. Pleural decompression and drainage during trauma reception and resuscitation. Injury, Int. J. Care Injured (2008) 39, 9—20
• Fuld H. Simple device for control of tension pneumothorax. BMJ. 1944;2:503.3
• http://www.ctsnet.org/article/history-thoracic-drainage-ancient-greeks-wound-sucking-drummers-digital-monitoring
• Ferrie et al. The right place in the right space. Awareness of Site of needle thoracosentesis. Emerg Med J 2002;19:176-177
• Ferrie E.P., Collum N., and McGovern S.: The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J 2005; 22: pp. 788-789
• Deakin C.D., Davies G., and Wilson A.: Simple Thoracostomy Avoids Chest Drain Insertion in Prehospital Trauma. J Trauma 1995; 39: pp. 373-374
• Heng K., Bystrzycki A., Fitzgerald M., et al: Complications of intercostal catheter insertion using EMST techniques for chest trauma ANZ. J Surg 2004; 74: pp. 420-423
• Beckett A, Savage E, Pannell D, et al. Needle Decompression for Tension Pneumothorax in Tactical Combat Casualty Care: Do Catheters Placed in the Midaxillary Line Kink More Often Than Those in

the Midclavicular Line? The Journal of Trauma: Injury, Infection, and Critical Care 2011;71:S408–12. doi:10.1097/TA.0b013e318232e558 [PMID 22071996]

• S. Bitten, S.H. Palmer, T.M. Snow. Needle thoracocentesis in tension pneumothorax; insufficient cannula length and potential failures, Injury, 27 (1996), pp321-322
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doi:10.1080/10903120802471998 [PMID 19145519]

• download.springer.com/static/pdf/222/art%253A10.1007%252Fs00134-014-3434-1.pdf?auth66=1425310437_db07b031374ad1de2ee348ad76bab12e&ext=.pdf
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• Leigh-Smith S., and Harris T.: Tension pneumothorax, time for a rethink? Emerg Med J 2005; 22: pp. 8-16
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• Struck MF et al. Bilateral False-Positive Tube Thoracostomy in Helicopter Emergency Medical Services. Air Medical Journal Assoc. Editorial 2015
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pp98-100

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Emergency Medicine Vol 13, No 2, pp155-161; 1995

• Davis, D et al. The safety and efficacy of prehospital needle and tube thoracostomy by aeromedical personnel. Prehospital Emergency Care [1090-3127] Davis yr:2005 vol:9 iss:2 pg:191 -7
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374

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• Weingart S. “Finger Thoracostomy Podcast” emcrit.org 10-30-2013

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