Needle thoracostomy may not be indicated in the trauma patient☆
Introduction
Prehospital needle thoracostomy catheter (NTC) placement is considered a potentially life-saving procedure, and has been routinely used by our prehospital personnel in cases of suspected tension pneumothorax. The procedure involves the placement of a 14-gauge intravenous catheter needle at the second interspace in the mid-clavicular line. The needle catheter is passed into the pleural space and should then relieve the tension pneumothorax. The procedure is described in the literature as being both diagnostic and therapeutic. Several cases of insufficient cannula length, misplaced catheters and catheters of insufficient diameter to relieve a tension pneumothorax have been reported [1], [2], [3]. At our institution, the placement of needle thoracostomy catheters in patients who did not appear to have a tension pneumothorax prompted us to evaluate the use of NTC placement by the regional prehospital personnel.
Section snippets
Materials and methods
The Institutional Review Board exempted this study from requiring approval due to its observational nature. All patients admitted to the Emergency Department from November 1996 to September 1997 with prehospital NTC were prospectively identified and evaluated. Criteria examined in these patients included: mechanism of injury, vital signs during transport (and on arrival in the Emergency Department), oxygen saturation, endotracheal intubation, signs of tension physiology (distended neck veins,
Results
Twenty-five NTCs were placed in 19 patients admitted during the study period. Six patients had bilateral NTCs (32%). The 19 patients represented 0.68% of total trauma admissions (2801) during the 9 months of the study. Fourteen of the patients were victims of blunt trauma; five were victims of penetrating trauma. Five of the patients were admitted while undergoing cardiopulmonary resuscitation, all died. All 14 patients arriving in the Emergency Department with signs of life survived to
Discussion
Tension pneumothorax occurs when intrapleural pressure exceeds atmospheric pressure throughout expiration. A communication between the lung parenchyma and the pleural space acts as a one way valve, allowing air to enter the pleural space during inspiration but preventing its egress during expiration [4]. Needle thoracostomy placement at the second intercostal space has been suggested as a temporary measure until definitive thoracostomy tube placement [5]. The NTC converts the tension
Summary
In our catchment area, it does not appear that NTCs are performed exclusively for tension pneumothorax. The benefit of prehospital NTC decompression is questionable. NTC placement should be limited to patients with a clear suggestion of tension pneumothorax, rather than simply ‘decreased breath sounds’. Further investigation as to the role of NTC decompression of the chest is warranted.
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Cited by (65)
Prehospital needle thoracostomy: What are the indications and is a post-trauma center arrival chest tube required?
2019, American Journal of SurgeryCitation Excerpt :Due to the potential complications, pNT should be limited to patients with clear clinical signs and symptoms suggestive of tPTX, rather than simply ‘decreased breath sounds. ‘4 The results of our study showed this was not the case as the majority of pNT attempts were performed for ‘reduced or absent breath sounds’ in 42 (66.7%) pNT attempts and only 5 (7.9%) pNT attempts were performed for hypotension.
Chest trauma: First 48 hours management
2017, Anaesthesia Critical Care and Pain MedicineFailure rate of prehospital chest decompression after severe thoracic trauma
2017, American Journal of Emergency MedicineCitation Excerpt :NT is as effective as TT for relieving tension pneumothorax in an animal 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.
Determination of the chest wall thicknesses and needle thoracostomy success rates at second and fifth intercostal spaces: a cadaver-based study
2016, American Journal of Emergency Medicine
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No grants or funding has been accepted for this study. Presented at the 29th Annual Meeting of the Western Trauma Association February 1998 in Lake Louise, Alberta Canada