Article, Emergency Medicine

Failure rate of prehospital chest decompression after severe thoracic trauma

a b s t r a c t

Introduction: Chest decompression can be performed by different techniques, like needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT).

The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effective- ness of these techniques.

Material and methods: In this retrospective case series study, all medical records of adult trauma patients under- going prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied.

Results: In a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen pa- tients had NT, six patients TT, one patient NT as well as TT, and no patients had LT. Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT re- lated complications were reported during hospitalization.

Conclusion: Prehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission.

(C) 2016

Introduction

Chest decompression is an infrequent, life-saving procedure in trau- ma patients suffering from a tension pneumothorax. It occurs infre- quently in trauma patients and interferes with cardioRespiratory function [1]. Therefore, rapid evaluation and Urgent treatment by needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT) is required in order to restore hemodynamic function and to im- prove respiration [1-3]. Needle thoracocentesis and TT were proved safe [4-6] and equally successful in the animal model [7]. Depending on the emergency medicine system, most commonly only designated emergency physicians are capable and allowed to perform TT, whereas NT may also be performed by skilled and educated paramedics.

Needle thoracocentesis is fast, simply applied, and used most com- monly in the prehospital setting or during resuscitation [8]. The overall

* Corresponding authors.

E-mail addresses: [email protected], [email protected]

(A. Kaserer), [email protected] (P. Stein), [email protected] (H.-P. Simmen), [email protected] (D.R. Spahn), [email protected] (V. Neuhaus).

incidence of complications of NT is low [4,9]. According to leading trau- ma guidelines (Advanced Trauma Life Support(R), Prehospital Trauma Life Support(R)) a needle or venous catheter should be inserted in the 2nd Intercostal space mid-clavicular line [2]. However, the report- ed success rate has a wide range varying from 5% to 96% [3,10-13]. One of the failure reasons is the insufficient length of standard needles and catheters for the 2nd ICS to reach the intrapleural space. Hence, some authors recommend the 5th ICS mid-axillar line for NT due to the small- er chest wall thickness in this area [14-18].

Tube thoracostomy ensures maximal Pleural cavity evacuation and lung re-expansion [1,3]. The procedure entails a thoracostomy prefera- bly in the 4th or 5th ICS mid-axillary line (Bulau) or the 2nd ICS midclavicular line (Monaldi), without any differences in the occurrence of misplacement or complications between both positions in trauma pa- tients [19]. Complications related to TT, such as damage to the thoracic wall, the lungs, to abdominal or mediastinal organs, are less common since the use of trocars has been abandoned in favor of blunt dissection [1]. However, in the prehospital setting TT is blamed to increase resus- citation time and infection rate. While data on prolongation of the prehospital resuscitation time is incongruent [20,21], higher infection rate due to TT was not observed so far [5,21,22].

http://dx.doi.org/10.1016/j.ajem.2016.11.057 0735-6757/(C) 2016

Lateral thoracostomy is performed by blunt dissection and digital decompression through the pleura in the 4th ICS mid-axillar line and may be considered as an alternative in mechanical ventilated patients [23]. As decompression of the pleural space is the primary goal during resuscitation of the hemodynamically instable patient with suspected hemato- or pneumothorax, insertion of a chest tube is optional [3].

The aim of this study was to report the incidence of prehospital chest decompression, to analyse the effectiveness of the used techniques and to show the consecutive diagnostic thoracic findings and further treat- ment in the resuscitation area.

Material and methods

Data analysis was started after obtaining approval of the local ethics committee (Kantonale Ethikkommission Zurich, Switzerland, KEK-ZH- No: 2011-0382, PB_2016_01888).

Study design and participants

In this retrospective single-center case series study all adult trauma patients admitted to the resuscitation area of the University Hospital Zurich between 2009 and 2015 were included. Patients treated with attempted chest decompression in the prehospital setting underwent detailed analysis.

Setting

The University Hospital Zurich (USZ) is one of twelve level-1 trauma centers in Switzerland. In the Swiss emergency medicine system, most commonly a team of two registered paramedics, with a 3-year advanced federal diploma of higher education, treat a patient on the scene and transport the patient to the trauma center. In case of life threatening emergencies like severe trauma, a designated emergency physician, skilled and trained in advanced airway management, resuscitation and application of TT and NT is brought in parallel and in addition to the prehospital scene of action. Tube thoracostomy may only be performed by the designated emergency physician, whereas paramedics may per- form NT. Later, in the resuscitation area of the hospital, a standardized Clinical approach according to leading trauma concepts (Advanced Trauma Life Support(R), European Trauma Course(R) and Definitive Surgi- cal Trauma Care(R)) is provided. A chest X-ray and an ultrasound of the abdomen are taken in case of an acute problem in the primary survey. To diagnose and evaluate most relevant injuries, a primary whole- body-CT-scan is performed as soon as the patient is stable or stabilized. The trauma staff includes at least one senior and one junior anaesthetist, one senior and one junior trauma surgeon and anesthesia as well as scrub nurses.

Variables and data collection

All medical records of the included patients were reviewed. The ICD 10 GM (International Classification of Diseases, 10th-Revision, German Modification [24,25]) codes were used to identify (thoracic) injuries and the CHOP codes (catalogue of the Swiss Surgery Classification Sys- tem [26]) for procedures. The data was encoded by professional medical coders.

Paramedic records of all patients undergoing prehospital chest de- compression were reviewed. Number and location of prehospital chest interventions were extracted from these records. Prehospital chest de- compressions were most commonly documented as NT and/or TT only, without information about catheter gauge and length. The treat- ment was defined as successful if any prehospital improvement in clin- ical (improved breath sounds or decreased dyspnoea if not intubated) and/or vital signs (improvement in systolic blood pressure, heart rate or oxygen saturation) was reported by paramedics or emergency physicians.

All chest X-rays and computed tomogram (CT) scans at admission were reviewed by the authors to analyse placement, location, and effect of the Chest tubes or needles (catheters) and to identify the presence of rib fractures, lung contusions, hemato- or pneumothoraces.

Statistical analyses

Only descriptive statistic was applied to analyse data. Categorical data were reported in absolute numbers (n) and percent (%), numerical data as mean and standard deviation (+-SD). All statistical analyses were performed by IBM SPSS Statistics 22 (SPSS Inc., Chicago, IL, USA).

Results

Cohort

In a 6-year period, 24 of 2261 (1.1%) trauma patients admitted to the resuscitation area obtained prehospital chest decompression (Table 1). The mean injury severity score was 37 +- 23. Pneumothorax was the leading traumatic finding, although it was not present in all patients undergoing prehospital chest decompression (Table 2). Other frequent injuries were rib fractures, flail chest, lung contusions and hematothoraces, while injuries of great vessels, of the bronchi or the di- aphragm were less common. Two patients had only superficial thoracic

injuries.

Prehospital needle thoracocentesis (NT)

Seventeen patients were treated with NT prior to arrival to the hos- pital (Fig. 1). All NT were performed at the 2nd ICS mid-clavicular line. Only three patients (18%) were – according to paramedic reports – suc- cessfully decompressed, although in all of these three patients, the needles were removed before admission or extrapleural in the primary CT scan (Fig. 2). Two of those patients received a TT in the resuscitation area to decompress a simple pneumothorax, while the third patient had no remaining pneumothorax and underwent no further treatment.

The majority (8 patients, 57%) of the unsuccessfully treated patients immediately received a TT in the resuscitation area at admission, before performing any X-ray or CT scan. An initial CT scan was performed in two patients, one requiring a TT directly afterwards due to a tension pneumothorax while the thoracocentesis needle was extrapleural. The other patient had no pneumothorax, although the needle was placed improperly, and needed no further TT after admission. In four patients, a chest X-ray was the first imaging method. Two of them had a tension hematothorax requiring an emergency department thoracotomy in the resuscitation area, one had a hematothorax requiring an urgent

Table 1

Overview.

n = 24

Age, mean (+-SD), years

43

(+-22)

Sex male

19

79%

Body mass index, mean (+-SD), (n = 18)

25.2

(+-3.1)

Blunt trauma

20

83%

Penetrating trauma

4

17%

prehospital endotracheal intubation

20

83%

prehospital cardiopulmonary resuscitation

3

13%

Prehospital needle thoracocentesis (NT)

17

71%

Prehospital chest tube thoracostomy (TT)

6

25%

Prehospital needle & chest tube

1

4%

ISS, mean (+-SD)

37

(+-23)

1-day mortality

6

25%

In-hospital mortality

11

46%

Length of hospital stay, mean (+-SD), days

15

(+-14)

Late complications related to TT or NT

0

Data reported as frequency with percentage or mean (+-SD). ISS, Injury Severity Score.

SD, Standard Deviation.

Table 2

thoracic injuries.

n = 24

Pneumothorax

17

71%

Rib fractures

15

63%

Flail chest or multiple rib fractures

12

50%

Lung contusions

12

50%

Hematothorax

11

46%

Cardiac injuries (e.g. contusio cordis)

5

21%

Thoracic great vessel injuries

3

13%

Diaphragmatic injuries

2

8%

Bronchus rupture

1

4%

No intrathoracic injuries

2

8%

Data reported as frequency with percentage.

thoracotomy and the last received a chest tube due to progressive respi- ratory impairment, although no signs of a pneumothorax in the X-ray were observed.

Prehospital chest tube thoracostomy (TT)

Six patients were treated with TT (Fig. 1). All chest tubes were inserted at the 4th or 5th ICS mid-axillary line. Treatment was successful in five patients (83%), although in two of these five patients, the chest tubes were not placed properly – not all drainage fenestrations of the chest tubes were intrapleural (Fig. 3). They had to be replaced in the re- suscitation area. Though transiently treated successfully, one patient re- ceived another chest tube in the resuscitation area and required an immediate sternotomy due to a cardiac gunshot wound with no previ- ous X-ray or CT. In one patient, TT was not successful because of a completely dislodged chest tube; the remaining tension pneumothorax was decompressed by another TT after admission.

Image of Fig. 2Fig. 2. (Example of an extrapleural needle) This figure shows a CT scan performed immediately after admission to the emergency department. NT was performed unsuccessfully on the left side at the 2nd ICS mid-clavicular line. The needle does not reach the pleural space. CT: computed tomography; NT: needle thoracocentesis; ICS: intercostal space;

Prehospital needle thoracocentesis and chest tube thoracostomy

One patient was treated first with NT and subsequently with TT in the prehospital setting (Fig. 1). Due to the proper placed chest tube

Fig. 1. Flowchart of all patients treated with needle thoracocentesis, tube thoracostomy or both in the prehospital setting. For patients undergoing prehospital chest decompression, success (judged by the paramedic team), first emergency department imaging, findings and diagnoses are presented. CT: computed tomography; NT: needle thoracocentesis; TT: chest tube thoracostomy;

Image of Fig. 3

Fig. 3. (Example of an improper chest tube) This figure shows a chest X-ray as an example of a misplaced chest tube. Prehospital TT was performed on the left side at the 4th ICS mid- axillar line, but the chest tube was not inserted deeply enough. One of the tube fenestrations remains extrapleural (arrow).TT: tube thoracostomy; ICS: intercostal space;

and no signs of a persistent pneumothorax in the CT scan, no further ac- tion was mandatory.

Discussion

Chest decompression can be accomplished by NT, TT, or LT. Typical indication is the suspicion of a tension pneumothorax in the prehospital setting. The decompression success rate is reported to be low. The aim of this study was to report the incidence in an urban area and to analyse the success of these emergency procedures. This study showed that prehospital chest decompression in severely injured patients is rare (1.1%), however in the reported range between 0.68% and 30% [1,3,10, 27]. The reported success rate by clinical judgement of TT was over 80% in contrast to the success rate of NT being lower than 20%. However, half of all chest tubes were dislodged or not properly placed but accomplishing decompression in most cases. Chest wall thickness or catheter lengths, questionable suspected diagnoses, incorrect or dislodged needle/catheter placements, and possible side effects of NT remain a big concern.

NT is as effective as TT for relieving tension pneumothorax in an an- imal model [7]. However, the success rate of 18% by NT in our study was low, in accordance with the already published range varying from 5% to 96% [3,10-13]. This low success rate is not completely surprising. Many emergency medicine services in our vicinity are using standard venous catheters with a length of 33 mm to 50 mm for chest decompression. It was shown, that the average chest wall thickness on the 2nd ICS mid- clavicular line is 38 mm for men and 52 mm for women [28]. The chest wall in the 5th ICS anterior-axillary line was 13 mm thinner on av- erage compared to the 2nd ICS mid-clavicular line [29]. A subcutaneous emphysema and multiple rib fractures may even increase chest wall thickness in trauma patients. Obesity increases chest wall thickness re- quiring at least a needle of 64 mm in length to be successful in 79% [30]. Also Zengerik et al. concluded that a greater needle length for certain population groups is necessary to improve the effectiveness of NT [31]. Inaba et al. performed a computed tomography-based analysis showing that NT decompression at the 2nd ICS mid-clavicular line would be expected to fail in 42.5% of cases compared to 16.7% at the 5th ICS in the anterior-axillar line if performed with standard venous catheters [29]. Several studies tackled this problem recently, investigat- ing the use of longer catheters or a different location for NT. It was

shown, that a catheter of at least 64 mm in length is needed to ensure that 95% of the patients would have a penetration of the pleural space for decompression [17]. If only standard venous catheters are available, NT of the 5th ICS anterior- or mid-axillar line may be considered to in- crease success, rate [28] although in this location the catheter might oc- clude more often during transport [32].

To diagnose a tension pneumothorax in the prehospital setting can be challenging. In our study three out of 17 patients (18%) treated with NT had no pneumothorax at all in the admission imaging. This in- dicates a questionable suspected diagnosis by paramedics and/or physi- cians on scene as well as an inadequate chest decompression maneuver. It was shown by Blaivas et al., that up to 26% of the patients treated with NT in the prehospital setting for a suspected tension pneumothorax, proved not to have had a pneumothorax originally [33], which was the case in three of our patients indicating another cause of the cardio- respiratory impairment.

Beside insufficient catheter length and questionable diagnosis on scene, hematothorax as the cause for respiratory distress may be anoth- er reason for an unsuccessful NT. All three patients in the study popula- tion suffering from a hematothorax underwent unsuccessful NT followed by urgent thoracotomy in the resuscitation area. These hematothoraces could be attributed to the thoracic injury mechanism and were not related to a NT complication.

Tube thoracostomy, or at least the lateral thoracostomy needed for tube insertion, in our study was safe and at least temporarily effective. Of the three misplaced chest tubes, only one failed due to primarily extrapleural placement. The remaining two misplaced chest tubes suc- cessfully relieved suspected tension pneumothorax, although not all drainage fenestrations were intrapleural (Fig. 3) on arrival to the hospi- tal. No organ damage caused by the insertion of the chest tube could be detected in the CT scans at admission. Although some case reports from misplaced and/or fatal chest tube insertions are published [34-36], the complication rate is shown to be low [5,6,19,22], especially since the use of the trocar has been mostly abandoned in favor of blunt dissection [1]. Therefore, some authors consider TT as the treatment of choice for initial chest decompression [3]. Data on the prolongation of the prehospital resuscitation time due to TT is incongruent [20,21], but there is no evidence for an increased risk of infection [5,21,22]. To keep the time to hospital admission as low as possible, a simple thoracostomy without chest tube insertion was proved safe and effec- tive and may be considered as an alternative to TT in mechanically ven- tilated patients [23], although this treatment was not observed in any of our patients.

Not all patients received a chest X-ray or CT scan immediately after admission. Those patients were generally in a critical condition suspected to require an urgent TT in order to improve cardiorespiratory function. Imaging was conducted as soon as the patients were stabi- lized, but those analyses did not allow to draw any conclusions about the initial placement of the needle or the presence of a pneumothorax. It may be that the NT did not improve the respiratory trouble or the NT transiently improved it, however it recurred.

Limitations

Our study has several limitations. First, it is a retrospective analysis. The correct indication to proceed with NT or TT cannot be verified. Sim- ilar, once TT and NT is performed correctly in the prehospital phase of care, one cannot be truly certain that the diagnosis of tension pneumo- thorax was correct. Second, paramedic record did not always report the size of the needles or catheters used for NT, limiting our analysis on ef- ficiency of different catheter lengths. Third, not all patients received a chest X-ray or CT scan directly after admission. Therefore, the initial placement of the needle or tube as well as the presence of a pneumotho- rax before further treatment in the resuscitation area remained unclear in some patients. The results may not be applicable to systems in which TT cannot be performed in the prehospital system and therefore the

focus must be on appropriate catheter length for NT as well as proper performance of the technique.

Conclusion

Prehospital NT or TT is infrequently required in trauma patients. NT is associated with a high failure rate, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission. Dif- ferent pathophysiological causes of cardiorespiratory distress (e.g. hematothorax) may also have made the paramedics to decompress the chest, without success. Better prehospital diagnostics may help to guide treatment.

Abbreviations

CHOP Swiss surgical procedures classification system CT Computed tomography

GCS Glasgow coma scale

ICS Intercostal space

ISS Injury severity score

LT Lateral thoracostomy

NT Needle thoracocentesis

RA Resuscitation area

SD Standard deviation

TT Tube thoracostomy

Declarations

Ethics approval and consent to participate

The local ethical committee of Zurich approved the study (KEK-ZH- No: 2011-0382, PB_2016_01888).

Competing interests

Dr. Spahn’s academic department is/has been receiving grant sup- port from the Swiss National Science Foundation, Berne, Switzerland, the Ministry of Health (Gesundheitsdirektion) of the Canton of Zurich, Switzerland for Highly Specialized Medicine, the Swiss Society of Anesthesiology and Reanimation (SGAR), Berne, Switzerland, the Swiss Foundation for Anesthesia Research, Zurich, Switzerland, Bundesprogramm Chancengleichheit, Berne, Switzerland, CSL Behring, Berne, Switzerland, Vifor SA, Villars-sur-Glane, Switzerland.

Dr. Spahn was the chair of the ABC Faculty and is the co-chair of the ABC-Trauma Faculty, managed by Physicians World Europe GmbH, Mannheim, Germany and sponsored by unrestricted educational grants from Novo Nordisk Health Care AG, Zurich, Switzerland, CSL Behring GmbH, Marburg, Germany and LFB Biomedicaments, Courtaboeuf Cedex, France.

In the past 5 years, Dr. Spahn has received honoraria or travel sup- port for consulting or lecturing from: Abbott AG, Baar, Switzerland, AMGEN GmbH, Munich, Germany, AstraZeneca AG, Zug, Switzerland, Baxter AG, Volketswil, Switzerland, Baxter S.p.A., Roma, Italy, Bayer, Zurich, Switzerland and Berlin, Germany, B. Braun Melsungen AG, Melsungen, Germany, Boehringer Ingelheim (Schweiz) GmbH, Basel, Switzerland, Bristol-Myers-Squibb, Rueil-Malmaison Cedex, France and Baar, Switzerland, CSL Behring GmbH, Hattersheim am Main, Germany and Berne, Switzerland, Curacyte AG, Munich, Germany, Daiichi Sankyo (Schweiz) AG, Thalwil, Switzerland, Ethicon Biosurgery, Sommerville, New Jersey, USA, Fresenius SE, Bad Homburg v.d.H., Germany, Galenica AG, Bern, Switzerland (including Vifor SA, Villars- sur-Glane, Switzerland), GlaxoSmithKline GmbH & Co. KG, Hamburg, Germany, Janssen-Cilag, Baar, Switzerland and Beerse, Belgium, LFB Biomedicaments, Courtaboeuf Cedex, France, Merck Sharp & Dohme AG, Luzern, Switzerland, Novo Nordisk A/S, Bagsvard, Denmark,

Octapharma AG, Lachen, Switzerland, Organon AG, Pfaffikon/SZ, Swit- zerland, PAION Deutschland GmbH, Aachen, Germany, Pharmacosmos A/S, Holbaek, Denmark, Photonics Healthcare B.V., Utrecht, Netherlands, ratiopharm Arzneimittel Vertriebs-GmbH, Vienna, Austria, Roche, Reinach, Switzerland, Sarstedt AG & Co., Numbrecht, Germany, Schering-Plough International, Inc., Kenilworth, New Jersey, USA, Tem International GmbH, Munich, Germany, Verum Diagnostica GmbH, Munich, Germany, Vifor Pharma, Munich, Germany, Vienna, Austria and St. Gallen, Switzerland.

All other authors have no competing interests to declare.

Funding

The study was not funded.

Authors contributions

AK contributed to data collection, statistical analysis, data interpreta- tion, drafting the manuscript and critical revision of the manuscript. PS contributed to data collection, Data interpretation, drafting the manu- script and critical revision of the manuscript. AK/PS contributed equally to the manuscript. DS and HS contributed to data interpretation and critical revision of the manuscript. VN participated in the design and co- ordination of the study, contributed to statistical analysis, data collec- tion and interpretation as well as drafting and critical revision of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

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