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Chest Wall Thickness and Decompression Failure: A Systematic Review and Meta-analysis Comparing Anatomic Locations in Needle Thoracostomy
... Finger Thoracostomy (FT) has been proposed after two unsuccessful attempts with NT. Several studies have raised concerns of adequate intrathoracic placement of needle decompression devices due to variations in technique, anatomical location of needle placement, and relative variability in chest wall thickness at different anatomical locations (Martin, 2012;Kaserer, 2017;Laan, 2016). Although FT (also referred to as open thoracostomy) has emerged as an alternative to needle thoracostomy, there is relatively little literature comparing finger and needle thoracostomy directly (Chesters,2016;Dickson, 2018;Massarutti, 2006;Hannon, 2020). ...
... This study showed a rate similar to this and other studies and is consistent with the current literature. This relatively low success rate is postulated to be secondary to a variety of factors including challenging conditions in out of hospital transport, chests wall anatomy (Martin, 2012;Laan, 2016), and concomitant traumatic injuries. Each method of thoracic decompression has its benefits and pitfalls, therefore clinical judgement centered on a patient-specific approach is warranted as this study cannot make a definitive statement to the best method for all patients. ...
... Continued education of out of hospital providers is necessary to educate them on alternatives to the current standard of care, especially if this technique is unsuccessful. There is a significant variability in the current literature regarding success of thoracic decompression by NT (Martin, 2012;Laan, 2016), therefore it is vital to re-assess our current standards for better alternatives to have improved patient outcomes. Additionally, with the increasing scope of out of hospital providers and the ability to perform additional procedures, our institution has deemed it vital that the standard techniques have mechanisms of quality control measures in place (e.g., reporting of rates of successful thoracic decompression or major injury from NT) to allow for process improvement. ...
Introduction: Tension pneumothorax related to chest trauma is a rapidly lethal condition that requires immediate treatment, often prior to arrival at definitive care. Recent concerns regarding the safety and efficacy of needle thoracostomy (NT) have led to alternatives. Finger thoracostomy (FT) is a potential life-saving treatment performed by prehospital providers as an alternative to NT. We hypothesize that FT has improved rates of prehospital thoracic decompression and is a safe alternative to NT. Materials and Methods: Retrospective cohort study of consecutive adult trauma patients presenting to a Level 1 trauma center who sustained chest trauma. A matched cohort of patients who underwent prehospital FT was compared to patients who underwent prehospital NT for thoracic decompression. Wilcoxon Rank Sum Test and Chi-Squared Analyses were performed for comparison of prehospital and in-hospital outcome variables. Results: 34 patients were compared, of which 15 underwent prehospital FT and 19 underwent prehospital needle thoracostomy NT. Groups were well matched in terms of demographics and injury characteristics. No difference in transport times were observed. All 15 patients in the FT group sustained cardiac arrest prior to arrival with 20% achieving return of spontaneous circulation (ROSC), while 6/19 NT patients arrived in cardiac arrest, with 66.7% achieving ROSC (p = 0.04). The rate of successful intrathoracic decompression was higher in the FT group (93.3% vs 47.4%, p<0.001). The NT group had a higher rate of chest tube placement (p=0.005). In-hospital mortality was not different between the two groups (p=0.213). Conclusions: FT is a viable alternative to NT for emergent thoracic decompression. The higher success rate of intrathoracic decompression supports the use of FT as an alternative to NT for prehospital tension pneumothorax, although future studies are needed establish superiority and further evaluate mortality and in-hospital outcomes.
... Typical locations are the second or third intercostal space (ICS) in the mid-clavicular line (MCL), the fourth or fifth ICS in the mid-axillary line (MAL), and the fourth or fifth ICS in the anterior axillary line (AAL). In a meta-analysis, the mean distance from the skin surface to the pleural space was reported to be 34 mm (CI, 28-41 mm) at the AAL and was thus the shortest distance when compared to other sites [63]. The mean distance was 40 mm (CI, 29-51 mm) at the MAL and 43 mm (CI, 39-47 mm) at the MCL. ...
... In some studies, the distance at the MCL was reported to be even shorter than that at the MAL [7,14]. The distance from the skin surface to the pleural space is significantly longer in women than in men [7,14,63]. In addition, there is a significant direct correlation between this distance and body mass index [64][65][66]. ...
... The use of a 3.2-cm cannula was associated with a failure rate of 65% [67]. Failure rates were considerably lower when a 5-cm cannula was used at the AAL (13%), MAL (31%), and MCL (38%) [63]. A failure rate of 89% was observed when a 5-cm cannula was used in obese patients (BMI > 30) [66]. ...
Purpose
Our aim was to review and update the existing evidence-based and consensus-based recommendations for the management of chest injuries in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.
Methods
MEDLINE and Embase were systematically searched to May 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies, and comparative registry studies were included if they compared interventions for the detection and management of chest injuries in severely injured patients in the prehospital setting. We considered patient-relevant clinical outcomes such as mortality and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.
Results
Two new studies were identified, both investigating the accuracy of in-flight ultrasound in the detection of pneumothorax. Two new recommendations were developed, one recommendation was modified. One of the two new recommendations and the modified recommendation address the use of ultrasound for detecting traumatic pneumothorax. One new good (clinical) practice point (GPP) recommends the use of an appropriate vented dressing in the management of open pneumothorax. Eleven recommendations were confirmed as unchanged because no new high-level evidence was found to support a change.
Conclusion
Some evidence suggests that ultrasound should be considered to identify pneumothorax in the prehospital setting. Otherwise, the recommendations from 2016 remained unchanged.
... All subjects (100%) reported training in NT, 10 (34%) were currently certified in PHTLS, and 16 (55%) had previously been PHTLS certified. Six (21%) had never performed a NT in the field, whereas 14 (48%) had performed five or more (range: [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. ...
... The optimal location for NT continues to be debated in the literature [12,13]. Both the second ICS MCL and the fourth/fifth ICS in the anterior axillary line (ICS 4/5-AAL) have been proposed as the preferred locations. ...
... Studies have looked at both its efficacy [11,15] and its safety [8,16] with proposals for different locations [7,12], equipment [17][18][19], and abandoning it all together in favor of finger thoracostomy [20]. This study adds to the impetus to improve upon the procedure by suggesting the preferred site for NT is simply difficult to find. ...
Introduction
Tension pneumothorax is an immediate threat to life. Treatment in the prehospital setting is usually achieved by needle thoracostomy (NT). Prehospital personnel are taught to perform NT, frequently in the second intercostal space (ICS) at the mid-clavicular line (MCL). Previous literature has suggested that emergency physicians have difficulty identifying this anatomic location correctly. We hypothesized that paramedics would also have difficulty accurately identifying the proper location for NT.
Methods
A prospective, observational study was performed to assess paramedic ability to identify the location for treatment with NT. Participants were recruited during a statewide Emergency Medical Services (EMS) conference. Subjects were asked the anatomic site for NT and asked to mark the site on a shirtless male volunteer. The site was copied onto a transparent sheet lined up against predetermined points on the volunteer’s chest. It was then compared against the correct location that had been identified using palpation, measuring tape, and ultrasound.
Results
29 paramedics participated, with 24 (83%) in practice for more than five years and 23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) reported training in NT, although six (21%) had never performed a NT in the field. Nine paramedics (31%) recognized the second ICS at the MCL as the desired site for NT, with 12 (41%) specifying only the second ICS, 11 (38%) specifying second or third ICS, and six (21%) naming a different location (third, fourth, or fifth ICS). None (0%) of the 29 paramedics identified the exact second ICS MCL on the volunteer. Mean distance from the second ICS MCL was 1.37 cm (interquartile range (IQR): 0.7-1.90) in the medial-lateral direction and 2.43 cm in the superior-inferior direction (IQR: 1.10-3.70). Overall mean distance was 3.12 cm from the correct location (IQR: 1.90-4.50). Most commonly, the identified location was too inferior (93%). Allowing for a 2 cm radius from the correct position, eight (28%) approximated the correct placement. 25 (86%) were within a 5 cm radius.
Conclusion
In this study, paramedics had difficulty identifying the correct anatomic site for NT. EMS medical directors may need to rethink training or consider alternative techniques.
... This can occur in blunt trauma through fractured ribs lacerating the visceral pleura or through a breach in the chest wall with penetrating trauma. Pressure buildup in one hemithorax pushes the mediastinal contents to the contralateral side, causing tension pneumothorax which can develop with visceral pleura disruption or tracheobronchial tree injury [1,2,5,7,[10][11][12]. ...
... Higher failure rates occur with improper placement, equipment malfunction, and insufficient knowledge of patient anatomy [1,2,7]. Many practitioners are unaware of the actual location of the ICS2-MCL and often identify this landmark as within the trauma box, a designated zone with a high likelihood of injury [12]. Another demerit that increases the chances of failure is the inaccurate subjective assessments of response by EMS personnel. ...
Background
Needle decompression is a useful tool in the pre-hospital setting for treating tension pneumothorax. However the specific improvements in vital signs that determine a successful decompression are only reported in a few studies and Emergency Medical Services (EMS) self-reported assessments of improvement are more commonplace. We hypothesize that EMS reports may exaggerate improvement when compared to objective vital sign changes.
Methodology
This is a retrospective cohort study using the National Emergency Medicine Information System (NEMSIS) for the year 2020. Vital signs recorded as objective endpoints include systolic blood pressure (SBP), pulse (HR), respiratory rate (RR), and oxygen saturation (SpO2). Univariate analysis was performed using the t-test for continuous variables and the chi-square test for categorical variables.
Results
A total of 8,219 calls were included in the sample size analyzed. Most patients were white (2,911, 35.4%) and male (6,694, 81.4%). Abnormal vitals recorded as indications for needle decompression included SBP <100 mmHg, HR <60 or >100 beats/minute, RR <12 or >20 breaths/minute, and SpO2 <93%. Statistically significant improvements were seen in the number of abnormal vital signs after the procedure. The percentage of improvement was higher in the EMS self-reported assessment than in objective findings for oxygen saturation and SBP.
Conclusions
Our analysis shows objective improvement of hypoxia and hypotension after field needle decompression, supporting the efficacy of the procedure. The improvement based on vital sign change is modest and is less than that reported by EMS assessment of global improvement. This represents a target for quality improvement in EMS practice.
... However, a recent systematic review and meta-analysis comparing the midclavicular line to the anterior axillary line site indicated a shorter insertion depth (3.42 cm vs. 4.28 cm) for the anterior axillary line. Therefore, in adults, the needle must be inserted in the fourth or fifth intercostal space at the anterior axillary line [64,65]. For pediatric patients, the needle must be inserted in the second intercostal space at the midclavicular line, as before. ...
Background: Trauma is a major global public health concern. Many countries are working to reduce preventable deaths; however, the mortality rate remains higher than their goal, indicating a need for continuous development in trauma care, including further improvements across the system. This article explores recent developments and updated guidelines for both prehospital emergency care and in-hospital trauma management, emphasizing evidence-based and patient-centered approaches. Current concepts: In the prehospital phase, the primary focus is on early and aggressive hemorrhage control using techniques such as tourniquet application, wound packing, and permissive hypotension as standard practices. Advancements in this field, including intraosseous vascular access and tranexamic acid administration, have improved patient outcomes. The emphasis on structured assessments, particularly “circulation, airway, breathing” (CAB) assessments, underscores the importance of managing life-threatening hemorrhages. During the in-hospital phase, the primary focus is on controlling bleeding. Protocols emphasize the judicious administration of fluids to prevent over-resuscitation and mitigate the risk of exacerbating coagulopathy. Efficient transfusion strategies are implemented to address hypovolemia, while ensuring balanced ratios of blood products. Furthermore, the implementation of advanced interfacility transfer systems and communication tools such as “Situation, Background, Assessment, Recommendation” (SBAR) plays a pivotal role in optimizing patient care and reducing delays in definitive treatment. Discussion and Conclusions: This review highlights the importance of implementing advanced strategies to align with international standards and further decrease the rate of preventable trauma-related deaths. Strengthening education and optimizing resource allocation for both prehospital and hospital-based trauma care are essential steps toward achieving these objectives.
... Additionally, The EPM was manufactured into a cubic shape measuring 4×4×8 cm and magnetized to N52 strength. This EPM can produce an anchoring force of 2.34 N on the IPM at the normal working distance of approximately 40 mm in surgical environment [35]. ...
Remote Actuation Mechanisms (RAMs) play a vital role in minimally invasive surgery (MIS) by providing motion capabilities within limited spaces. This paper first focused on analyzing commonly employed RAMs to understand their strengths and limitations. Then, drawing inspiration from bionics and the biological structure of scorpions, we proposed a novel approach by integrating three RAMs–a magnet pair, a torque coil, and a soft bellow–to create a 5-degree-of-freedom (5-DOF) miniature remote actuation robot. In the design phase, we established the robot’s parameters using the magnetic dipole model and related constraints. A functional prototype of the robot, along with an external controller and user interface, was fabricated and assembled. Experimental investigations demonstrated motion performance across the 5 DOF, validating the robot’s feasibility. To assess the practicality of the system, the interaction interface was evaluated under controlled laboratory conditions and through a cadaver test. In conclusion, our innovative approach combines multiple RAMs into a 5-DOF remote actuation robot. Comprehensive tests validated its motion capabilities and highlighted its potential to advance MIS procedures.
... The second ICS MCL is the most common decompression location. More recent literature suggests that catheters placed in the second ICS MCL are prone to higher failure rates compared to the fifth ICS MAL (42.5% versus 16.7%, respectively) [15,16]. Ultimately, chest thoracostomies are the definitive treatment for tension pneumothorax [3]. ...
Background: A tension pneumothorax is a condition that results in elevated pressure within the pleural space. The effective management of tension pneumothorax relies on needle decompression, commonly performed at the second intercostal space (ICS) midclavicular line (MCL). However, some literature suggests that catheters placed in the second intercostal space midclavicular line are prone to higher failure rates compared to the fifth intercostal space midaxillary line (MAL) (42.5% versus 16.7%, respectively). In this study, we aim to identify and scrutinize the prevalence of prehospital needle decompression from one tertiary care center over eight years and examine their trends, efficacies, or pitfalls. It is hypothesized that preclinical providers are performing needle decompression prematurely and unnecessarily.
Methods: A set of 90 patient records obtained using the trauma registry at Saint Francis Hospital, Tulsa, Oklahoma, were retrospectively reviewed to evaluate the management and outcomes of tension pneumothorax, as well as the indications documented for needle decompression. Patient charts were reviewed via Epic Hyperspace (Epic, Madison, WI). The Oklahoma Emergency Medical Service Information System (OKEMSIS) also provided information contributing to the sample population.
Results: The most documented indications for needle decompressions included diminished or absent breath sounds (52.70%), hypoxia (15.54%), hypotension, and hemodynamic instability (6.76%). Emergency medical services (EMS) reported improvements in 51 (56.67%) patients after needle thoracostomy. Improvements in vital signs after needle decompression were sporadic. The most common complication was catheter dislodging, which occurred most in the second intercostal space midclavicular line. Only nine patients had an oxygen saturation (SpO2) below 92% and a systolic blood pressure (SBP) below 100 mm Hg prior to receiving needle decompression.
Conclusion: Current practices for tension pneumothorax show little improvement in vital signs before and after needle decompression. Vital signs prior to needle decompression often do not indicate tension pneumothorax physiology. Preclinical providers may be inappropriately performing needle decompressions, an invasive procedure with complications.
... In a study by Inaba et al. involving 20 cadavers [12], the success rate of using a 5 cm needle at the ffth ICS was 100%, whereas that at the second ICS was only 58%, indicating that the CWT at the second ICS was relatively thicker. A metaanalysis by Laan et al. indicated that the CWT at the fourth or ffth ICS-AAL was smaller than that at the second ICS-MCL in multiple populations [19]. Elhariri et al. pointed out that the CWT at the ffth ICS-MAL was signifcantly less than second ICS-MCL and an 8 cm length catheter had a better efcacy in comparison to 5 cm catheter [16]. ...
Background:
There are very few professional recommendations or guidelines on the needle thoracentesis decompression (NTD) for the tension pneumothorax in the elderly. This study aimed to investigate the safety and risk factors of tension pneumothorax NTD in patients over 75 years old based on CT evaluation of the chest wall thickness (CWT).
Methods:
The retrospective study was conducted among 136 in-patients over 75 years old. The CWT and closest depth to vital structure of the second intercostal space at the midclavicular line (second ICS-MCL) and the fifth intercostal space at the midaxillary line (fifth ICS-MAL) were compared as well as the expected failure rates and the incidence of severe complications of different needles. We also analyzed the influence of age, sex, presence or absence of chronic obstructive pulmonary disease (COPD), and body mass index (BMI) on CWT.
Results:
The CWT of the second ICS-MCL was smaller than the fifth ICS-MAL both on the left and the right side (P < 0.05). The success rate associated with a 7 cm needle was significantly higher than a 5 cm needle (P < 0.05), and the incidence of severe complications with a 7 cm needle was significantly less than an 8 cm needle (P < 0.05). The CWT of the second ICS-MCL was significantly correlated with age, sex, presence or absence of COPD, and BMI (P < 0.05), whereas the CWT of the fifth ICS-MAL was significantly correlated with sex and BMI (P < 0.05).
Conclusion:
The second ICS-MCL was recommended as the primary thoracentesis site and a 7 cm needle was advised as preferred needle length for the older patients. Factors such as age, sex, presence or absence of COPD, and BMI should be considered when choosing the appropriate needle length.
... Classically, it is performed in the Monaldi position in the second or third intercostal space of the midclavicular line. The indwelling venous cannulae often used for needle decompression are too short to reach the pleural space for a relevant proportion of patients [115,116]. For this reason, relevant course formats alternatively recommend needle decompression in the Bülau position in the fourth or fifth intercostal space between the anterior and midaxillary line (Figure 3) [117,118]. ...
Background:
Despite numerous promising innovations, the chance of survival from sudden cardiac arrest has remained virtually unchanged for decades. Recently, technological advances have been made, user-friendly portable devices have been developed, and advanced invasive procedures have been described that could improve this unsatisfactory situation.
Methods:
A selective literature search in the core databases with a focus on randomized controlled trials and guidelines.
Results:
Technical aids, such as feedback systems or automated mechanical cardiopulmonary resuscitation (CPR) devices, can improve chest compression quality. The latter, as well as extracorporeal CPR, might serve as a bridge to treatment (with extracorporeal CPR even as a bridge to recovery). Sonography may be used to improve thoracic compressions on the one hand and to rule out potentially reversible causes of cardiac arrest on the other. Resuscitative endovascular balloon occlusion of the aorta might enhance myocardial and cerebral perfusion. Minithoracostomy, pericardiocentesis, or clamshell thoracotomy might resolve reversible causes of cardiac arrest.
Conclusions:
It is crucial to identify those patients who may benefit from an advanced or invasive procedure and make the decision to implement the intervention in a timely manner. As with all infrequently performed procedures, sound education and regular training are paramount.
... Page 2 of 7 often surgically repairable in an operating room [14,15,16,17], could result in (preventable) fatality in a spacecraft or other isolated, resource-poor environments. Tools must be positioned and oriented correctly to avoid accidental insertion into critical structures [18,19], and they must be inserted no further than the thin membrane lining the inside of the rib cage (i.e., the parietal pleura, see Fig. 1). Operators identify pleural puncture via loss-ofresistance (LoR) sensations on the tool during advancement, but experienced surgeons anecdotally describe a wide range of membrane characteristics: robust tissues require significant force to perforate, while fragile tissues deliver little-to-no haptic sensation when pierced. ...
Astronauts are at risk for pneumothorax, a condition where injury or disease introduces air between the chest wall and the lungs (i.e., the pleural cavity). In a worst-case scenario, it can rapidly lead to a fatality if left unmanaged and will require prompt treatment in situ if developed during spaceflight. Chest tube insertion is the definitive treatment for pneumothorax, but it requires a high level of skill and frequent practice for safe use. Physician astronauts may struggle to maintain this skill on medium-and long-duration exploration-class missions, and it is inappropriate for pure just-in-time learning or skill refreshment paradigms. This paper proposes semi-automating tool insertion to reduce the risk of complications in austere environments and describes preliminary experiments providing initial validation of an intelligent prototype system. Specifically, we showcase and analyse motion and force recordings from a sensorized percutaneous access needle inserted repeatedly into an ex vivo tissue phantom, along with relevant physiological data simultaneously recorded from the operator. When coupled with minimal just-in-time training and/or augmented reality guidance, the proposed system may enable non-expert operators to safely perform emergency chest tube insertion without the use of ground resources.
... This study showed that difficulties in cricothyroidotomy may arise from the anatomical factors such as the thickness of the skin of the patient's neck. [4] Some previous studies showed that standard medical procedures may be inadequate for severely obese patients [8][9][10]. Obese people may need different equipment for needle decompression of a tension pneumothorax, due to larger chest wall thickness. ...
INTRODUCTION: Needle cricothyrotomy is a method of maintaining airways in emergency situations. One of the identified factors that can make this procedure difficult to perform is ‘a difficult neck anatomy’ or a short obese neck. Due to the growing problem of obesity, we decided to estimate the feasibility of a needle cricothyrotomy by measuring the thickness of neck fat tissue in the population. Evaluation of this method is important because it is the only method that can be legally performed by paramedics in Poland. The aim of the study was to estimate the feasibility of needle cricoidectomy by evaluating the percentage of population in which the thickness of subcutaneous fat tissue could potentially limit or complicate such a procedure. MATERIAL AND METHODS: In this retrospective study we reviewed computed tomography (CT) scans of the neck from the database at the Department of Radiology, University Hospital in Cracow. 550 CT scans met inclusion criteria: age of patient over 18 years old, lack of any lesions altering the anatomy of measured region of neck, the first CT scan of patient. 50.36% of patients were women. The median age was 61 years (range 18–93). The distance from the skin surface at the level of the lower edge of the thyroid cartilage to the cricothyroid ligament (surface — ligament distance, SLD) was measured. Statistical analysis of the data was performed using R software (R version 4.0.3). RESULTS: Median SLD was 1.41 (1.01–2.04). Subcutaneous fat tissue was thicker than maximal depth of application of cricothyrotomy (3 cm) device in 31 patients (5.64%). CONCLUSIONS: Performing needle cricothyrotomy may be limited to a considerable percentage of the population (5.64%).
... Laan et al. [23], measured 6192 anatomical sites to determine the CWT at the 4th/5th ICS-AAL and 4th/5th ICS-MAL. The results showed that the mean (95% confidence interval) CWT was 39.85 (28.70-51.00) ...
Background
Dissecting lymph nodes along the left recurrent laryngeal nerve (LRLN) is the most challenging step in thoracoscopic-assisted esophagectomy. To retract the proximal esophagus in the existing lymphadenectomy methods, either a special trocar is required to insert and take out endoscopic instruments or thoracic punctures are needed to externally retract the esophageal loop. Therefore, advanced skills for esophageal traction are important to facilitate the LRLN lymphadenectomy and to reduce the incidence of trauma to the chest wall. Herein, we present the magnetic anchoring and traction technique, a novel method for LRLN lymphadenectomy during thoracoscopic esophagectomy.
Methods
The magnetic anchoring traction system was successfully used to retract the upper thoracic esophagus and to help expose the upper mediastinum in 10 cases of thoracoscopic-assisted esophagectomy. When the external magnet was moved outside of body, the internal magnet was coupled with a magnetic force to pull the proximal esophagus to the appropriate direction, which helped to expose the LRLN and adjacent lymph nodes. The lymph nodes adjacent to the LRLN could then be dissected completely without any damage to the nerve.
Results
In all surgeries, the LRLN and adjacent lymph nodes were well visualized, and the number of trocars used to pass endoscopic instruments for retraction of the proximal esophagus or the number of thoracic punctures for external traction of the esophagus during the surgery were reduced.
Conclusions
In thoracoscopic-assisted esophagectomy, the magnetic anchoring and traction technique can improve the exposure of the LRLN, facilitate LRLN lymphadenectomy, and reduce chest wall trauma.
... Decompression of a pneumothorax should follow local guidelines. Note that recent evidence and guidelines report higher success from decompression in the fifth intercostal space, anterior axillary line as opposed to the second intercostal space, midclavicular line (29). ...
Airway emergencies and respiratory failure frequently occur in the prehospital setting. Patients undergoing advanced airway management customarily receive manual ventilations. However, manual ventilation is associated with hypo- and hyperventilation, variable tidal volumes, and barotrauma, among other potential complications. Portable mechanical ventilators offer an important strategy for optimizing ventilation and mitigating ventilatory complications.
• EMS clinicians, including those performing emergency response as well as interfacility transports, should consider using mechanical ventilation after advanced airway insertion.
• Prehospital mechanical ventilation techniques, strategies, and parameters should be disease-specific and should mirror in-hospital best practices.
• EMS clinicians must receive training in the general principles of mechanical ventilation as well as detailed training in the operation of the specific system(s) used by the EMS agency.
• Patients undergoing mechanical ventilation must receive appropriate sedation and analgesia.
... This study showed that di culties in cricothyroidotomy may arise from the anatomical factors such as the thickness of the skin of the patient's neck. [4] Some previous studies showed that standard medical procedures may be inadequate for severely obese patients [8,9,10]. Obese people may need different equipment for needle decompression of a tension pneumothorax, due to larger chest wall thickness. ...
Background
Needle cricothyrotomy is a method of maintaining airways in emergency situations. One of identified factors that can make this procedure difficult to perform is ‘difficult neck anatomy’ or short obese neck. Due to the growing problem of obesity, we decided to estimate feasibility of needle cricothyrotomy by measuring the thickness of neck fat tissue in the population. Evaluation of this method is important because it is the only method that can be legally performed by paramedics in Poland. The aim of the study was to estimate feasibility of needle cricoidectomy by evaluating the percentage of population in which the thickness of subcutaneous fat tissue could potentially limit or complicate such a procedure.
Methods
In this retrospective study we reviewed CT scans of the neck from a database at the Department of Radiology, University Hospital in Cracow. 550 CT scans met inclusion criteria: age of patient over 18 years old, lack of any lesions altering anatomy of measured region of neck, the first CT scan of patient. 50.36% of patients were women. Median age was 61 years (range 18 – 93). The distance from the skin surface at the level of the lower edge of the thyroid cartilage to the cricothyroid ligament (surface - ligament distance, SLD) was measured. Statistical analysis of the data was performed using R software (R version 4.0.3).
Results
Median SLD was 1.41 (1.01 - 2.04). Subcutaneous fat tissue was thicker than maximal depth of application of cricothyrotomy (3cm) device in 31 patients (5.64%).
Conclusions
Performing needle cricothyrotomy may be limited in a considerable percentage of population (5.64%).
Background
Trauma is a leading cause of preventable death, with a significant portion of trauma deaths occurring in the prehospital setting. Interventions such as chest drainage may play a critical role in managing life‐threatening conditions but face challenges due to poorly defined indications and reliance on anecdotal evidence rather than rigorous studies. Among chest drainage techniques, finger thoracostomy (FT) is a well‐described, but controversial, method for decompressing the pleural cavity in emergencies like tension pneumothorax or hemothorax. Despite its simplicity and minimal equipment requirements, FT carries risks, including bleeding, infection, organ injury, temporary effects, and procedural failure.
Study Design and Methods
This study examines eight FT procedures performed by Israel Defense Forces providers during the 2023–2024 “Swords of Iron” War in Gaza.
Results
All patients sustained severe penetrating injuries, with mixed outcomes. One case highlighted severe complications, including infection and empyema weeks later. Additionally, challenges in maintaining up‐to‐date knowledge and adherence to protocols among reservists led to unauthorized FT procedures, emphasizing the dangers of improvisation without evidence.
Discussion
Our findings, coupled with limited evidence for FT's effectiveness in prehospital settings, raise questions about its appropriateness in trauma care. These concerns highlight the critical importance of adhering to validated and evidence‐based protocols in all aspects of medical practice. Deviating from such protocols not only introduces unnecessary risks but also undermines the standardization essential for optimal patient care. Further research is needed to clarify the role, if any, of FT in prehospital trauma management.
Background: Trauma remains a significant public health challenge in Korea, with preventable trauma-related death rate declining from 45% in 1999 to 13.9% in 2021 following advancements such as the establishment of regional trauma centers in 2012. This preventable trauma-related death rate in South Korea remains higher than that in advanced nations, highlighting the need for further refinement of trauma care. This article reviews the recent advancements and updated guidelines for prehospital emergency care and in-hospital trauma management, emphasizing evidence-based, patient-centered approaches.Current Concepts: In the prehospital phase, early and aggressive hemorrhage control is prioritized, with techniques such as tourniquet application, wound packing, and permissive hypotension becoming standard. Innovations, such as intraosseous vascular access and tranexamic acid administration, have improved outcomes. The emphasis on structured assessments, including the circulation, airway, and breathing (CAB) assessment, reflects the importance of controlling life-threatening hemorrhages. In the in-hospital phase, bleeding control is the central focus, with protocols established to emphasize the cautious use of fluids to avoid over-resuscitation and worsening coagulopathy. Efficient transfusion strategies are prioritized to address hypovolemia while maintaining balanced ratios of blood products. Additionally, streamlined interfacility transfer systems and improved communication tools, such as the situation, background, assessment, and recommendation (SBAR) tool, help to optimize patient care and minimize delays in receiving definitive treatment.Discussion and Conclusion: This review underscores the need to adopt advanced strategies that align with international standards and further reduce preventable trauma-related deaths. Enhanced education and resource allocation for prehospital and hospital-based trauma care are crucial for achieving these goals.
Introducción. El neumotórax espontáneo es una patología infrecuente, que afecta tanto a jóvenes como a personas mayores. Puede tener alta tasa de recurrencia, generando morbilidad y, en ocasiones, mortalidad a los pacientes. En nuestro medio no disponemos de datos epidemiológicos de la enfermedad, lo que motivó la realización de este estudio. Métodos. Estudio retrospectivo de una base de datos prospectiva, que incluyó pacientes mayores de 14 años con diagnóstico de neumotórax espontáneo intervenidos quirúrgicamente en el Hospital Pablo Tobón Uribe, de Medellín, Colombia, entre enero de 2018 y diciembre de 2023. Se analizaron variables sociodemográficas, clínicas y desenlaces postquirúrgicos a 30 días de la intervención. Resultados. El sexo masculino fue el más afectado (68,2 %), el neumotórax espontáneo secundario predominó (56,8 %) y el hemitórax derecho fue la localización más común (63,6 %). Se encontró una incidencia similar entre fumadores (45,4 %) y no fumadores (52,3 %). La resección en cuña fue el tratamiento definitivo en el 50 % de los pacientes y la resección en cuña asociada a pleurodesis mecánica en el 31,8 %. La complicación más frecuente fue la fuga persistente de aire. Se registró una recurrencia de neumotórax en un paciente que había sido sometido a resección en cuña. Al final del estudio, cinco pacientes fallecieron: tres habían sido tratados únicamente con toracostomía y dos habían sido llevados a cirugía. Conclusiones. El neumotórax espontáneo es una patología infrecuente. Las causas y la población afectada varían de acuerdo con su clasificación. En nuestro medio, la tuberculosis tiene mayor relevancia por ser una enfermedad endémica.
Emergency medical services (EMS) clinicians manage patients with traumatic pneumothoraxes. These may be simple pneumothoraxes that are less clinically impactful, or tension pneumothoraxes that disturb perfusion, lead to shock, and impart significant risk for morbidity and mortality. Needle thoracostomy is the most common EMS treatment of tension pneumothorax, but despite the potentially life-saving value of needle thoracostomy, reports indicate frequent misapplication of the procedure as well as low rates of successful decompression. This has led some to question the value of prehospital needle thoracostomy and has prompted consideration of alternative approaches to management (e.g., simple thoracostomy, tube thoracostomy). EMS clinicians must determine when pleural decompression is indicated and optimize the safety and effectiveness of the procedure. Furthermore, there is also ambiguity regarding EMS management of open pneumothoraxes. To provide evidence-based guidance on the management of traumatic pneumothoraxes in the EMS setting, the National Association of EMS Physicians (NAEMSP) performed a structured literature review and developed the following recommendations supported by the evidence summarized in the accompanying resource document.
Magnetic anchored and guided system(MAGS) is a promising solution for minimally invasive surgery, particularly in the realm of endoscope robotics. However, the inherent tight tissue contact in MAGS limits certain degrees of freedom, constraining the surgeon’s ability to adjust the field of view. To address this, we propose a novel solution by combining magnetic actuation with a cable-driven flexible link. Our study encompasses the design, analysis of magnetic force/torque, and kinematics of the flexible link. One prototype was fabricated, and experiments, including the evaluation of magnetic coupling performance and the motion of the flexible link, were conducted. These experiments validated both the theoretical modeling and the functionality of the magnetic endoscope system.
Introduction
Pneumothorax (PTX) incidence in patients arriving to a trauma center can be as high as 20%. The severity of PTX can range from insignificant to life-threatening. Five percent of combat casualties sustaining thoracic trauma have tension PTX (tPTX) at the time of death. Rapid diagnosis and decompression, traditionally with a needle decompression in the prehospital setting, is essential. However, high iatrogenic injury rates reveal a need for a device with the potential to decrease injury rate without compromising decompression success. The Donaldson Decompression Needle (DDN) is a 10-gauge × 3.25 inch needle with a locking mechanism designed to prevent over-insertion. During insertion, a spring-loaded blunt tip retracts, releasing the lock. After penetration of the parietal pleura, the blunt tip projects forward, which in turn locks the device in place on the chest. The device also contains an integrated 1-way valve (OWV) to prevent causing iatrogenic PTX, if placed into a healthy lung cavity.
Materials and Methods
We compared the DDN against a standard-of-care (SOC) needle (E-ARS 10 gauge × 3.25”) in a cadaveric randomized crossover design study. Tension pneumothorax was created by inserting a needle adjacent to the sternum and insufflating to 15 mmHg. Data collected included participant demographics/experience, cadaver measurements, and procedure data such as intrathoracic pressures and decompression time. Participants also completed a postprocedure survey. A secondary objective was evaluation of decompression rate with the OWV on vs. off.
Results
Twenty participants were enrolled in the study. Five participants required exclusion. While there were no differences in set-up times for the 2 procedures (DDN vs. SOC, 33 seconds vs. 28 seconds, P = .63), the decompression times were significantly different between the 2 groups (DDN vs. SOC, 2:06 vs. 1:06, P = .019). Evaluation of the secondary outcome resulted in 18 repetitions. The average decompression time for the OWV on group (n = 9) vs. OWV off group (n = 9) was 44 seconds vs. 10 seconds (P=<.05).
Conclusions
Despite the similar length and gauge of the DDN compared to the standard of care (SOC), the success rate of thoracic decompression was lower for the DDN when compared to the SOC (46% vs. 87%, P = .077) although statistical noninferiority was not established. Additionally, intradevice comparisons indicated decompression with the OWV on significantly prolonged decompression time when compared to when it was removed. It could be appropriate to consider removing the OWV after placement to decrease the decompression time, followed by reattachment for transport. Further research into the ability of the DDN to decrease iatrogenic injury will follow validation of decompression capabilities.
Background
Needle thoracostomy is a potentially life-saving intervention for tension pneumothorax but may be overused, potentially leading to unnecessary morbidity.
Objective
To review prehospital needle thoracostomy indications, effectiveness, and adverse outcomes.
Methods
A retrospective cohort study was conducted based on registry data for a United States Midwestern Level I trauma center for a 7.5-year period (January 2015 to May 2022). Included were patients who received prehospital needle thoracostomy and trauma activation before hospital arrival. The primary outcomes were correct indications and improvement in vital signs. Secondary outcomes were the need for chest tubes, correct needle placement, complications, and survival.
Results
A total of n = 67 patients were reviewed, of which n = 63 (94%) received a prehospital thoracostomy. Of the 63 prehospital thoracostomies, 54 (86%) survived to arrival. Of these 54, 44 (n = 81%) had documented reduced/absent breath sounds, 15 (28%) hypotension, and 19 (35%) with difficulty breathing/ventilating. Only four patients met all three prehospital trauma life support criteria: hypotension, difficulty ventilating, and absent breath sounds. There were no significant changes in prehospital vitals before and after receiving needle thoracostomy. In patients receiving imaging (n = 54), there was evidence of 15 (28%) lung lacerations, 6 (11%) of which had a pneumothorax and 3 (5%) near misses of important structures. Review of needle catheters visible on computer tomography imaging found 11 outside the chest and 1 in the abdominal cavity.
Conclusion
The study presents evidence of potential needle thoracostomy overuse and morbidity. Adherence to specific guidelines for needle decompression is needed.
Background: Patent foramen ovale (PFO) is a distinctive aetiology of cryptogenic stroke. The established benchmark for diagnosing PFO is the transoesophageal echocardiography with agitated saline or ‘bubble’ (TOE-b) study. Transcranial Doppler with bubble (TCD-b) or transthoracic echocardiography with bubble (TTE-b) examinations are common initial screening tests for PFO. However, the degree of concordance and discordance between the results of these two approaches remain unclear. Methods: In this prospective observational study, individuals presenting with suspected PFO-associated stroke between 2018 and 2021 underwent simultaneous TCD-b and TTE-b examinations within a joint neuro-cardiovascular laboratory to assess rates of concordance and discordance between TCD-b and TTE-b results. Additionally, data from any subsequent TOE-b studies were gathered. Results: Twenty-two patients were included. Ten patients (45%) exhibited concordantly negative findings and seven patients (32%) had concordantly positive results. Discordant outcomes were recorded in five patients (23%). Subsequently, a subset of seven patients (32%) underwent TOE-b, which confirmed the presence of right-to-left shunts. Among these cases, TCD-b consistently and accurately identified right-to-left shunts in all instances. In contrast, four out of these seven cases exhibited negative TTE-b results. Conclusion: This study indicates that there is significant discordance between TCD-b and TTE-b results (five of 22; 23%). Additionally, the results suggest that TCD-b might be a more effective screening test for detecting PFO compared with TTE-b.
The Advanced Trauma Life Support (ATLS®) system allows for standardization in the management of the trauma patient. It places an emphasis on prioritizing a systematic approach to patient care, with the single unifying goal of identifying and intervening on life-threatening injuries. The primary survey groups certain key systems that would contribute to a hastened demise into an initial assessment. This is quickly followed by the secondary survey, allowing the care team to assess associated injuries and establish a care plan.
This protocol applies in both military and civilian settings and reduces mortality, expedites patient care, and improves outcomes. ATLS® promotes high-quality care that is evidence-based and protocolized, thereby minimizing clinician and facility variations in care. It facilitates a team-based approach, allowing for expeditious coordination of diagnostics and therapeutics.
Purpose: This study aimed at developing a novel tube thoracostomy technique using the sternum, a fixed anatomical structure, as an indicator to reduce the possibility of incorrect chest tube positioning and complications in patients with chest trauma.Methods: This retrospective study analyzed the data of 184 patients with chest trauma who were aged ≥18 years, visited a single regional trauma center in Korea between April and June 2022, and underwent chest computed tomography (CT) with their arms down. The conventional gold standard, 5th intercostal space (ICS) method, was compared to the lower 1/2, 1/3, and 1/4 of the sternum method by analyzing CT images. Results: When virtual tube thoracostomy routes were drawn at the mid-axillary line at the 5th ICS level, 150 patients (81.5%) on the right side and 179 patients (97.3%) on the left did not pass the diaphragm. However, at the lower 1/2 of the sternum level, 171 patients (92.9%, P<0.001) on the right and 182 patients (98.9%, P= 0.250) on the left did not pass the diaphragm. At the 5th ICS level, 129 patients (70.1%) on the right and 156 patients (84.8%) on the left were located in the safety zone and did not pass the diaphragm. Alternatively, at the lower 1/2, 1/3, and 1/4 of the sternum level, 139 (75.5%, P=0.185), 49 (26.6%, P<0.001), and 10 (5.4%, P<0.001), respectively, on the right, and 146 (79.3%, P=0.041), 69 (37.5%, P<0.001), and 16 (8.7%, P<0.001) on the left were located in the safety zone and did not pass the diaphragm. Compared to the conventional 5th ICS method, the sternum 1/2 method had a safety zone prediction sensitivity of 90.0% to 90.7%, and 97.3% to 100% sensitivity for not passing the diaphragm.Conclusions: Using the sternum length as a tube thoracostomy indicator might be feasible.
Dyspnea describes the subjective feeling of insufficient or difficult breathing. There are many reasons triggering the symptom, which is why it is not uncommon to be alerted with the emergency keyword “acute dyspnea”. This article reviews the most important differential diagnoses and describes common therapy options.
Military trauma provides a unique pattern of injuries due to the high velocity, high kinetic energy ammunition utilized, and the high prevalence of blast injury. To further complicate this, military trauma often occurs in austere environments with limited logistical support. Therefore, military medical providers are forced to learn nonstandard techniques and when necessary, practice a level of improvisation not commonly seen in other medical fields. The case presented in this manuscript is a prime example of these challenges. At the onset of fighting both the medic’s rucksack, carrying with it the primary source of medical gear and the precious supply of cold-stored blood products are lost. The scenario was further complicated by rough mountainous terrain and a prolonged evacuation time. The medical provider was forced to utilize nonstandard devices such as an improvised junctional tourniquet which used a rock to focus the devices pressure. They also adapted their basic understanding of surgical procedures to conduct a vascular cutdown procedure for wound exposure and effectively pack an otherwise non-compressible wound to a major artery. Despite a significant loss of equipment, the medic and their team were able to successfully care for a number of patients in this mass casualty scenario.
Purpose of Review
This review will describe pathophysiology, current emergency department (ED) treatment strategies, and novel devices used in the management of acute tension pneumothorax.
Recent Findings
Traditional decompression success rates for the treatment of acute tension pneumothorax utilizing a standard 5-cm angiocatheter are inadequate in many cases. Novel devices and anatomical approaches have recently been developed to improve upon the rate of successful decompression and treatment.
Summary
Recent studies have shown greater success in emergent decompression of acute tension pneumothorax at the 4th or 5th intercostal space along the anterior axillary line, when compared to the traditional decompression site at the 2nd or 3rd intercostal space at the mid clavicular line. The standard 5-cm catheter used for decompression may not be long enough in many patients to reach the intrapleural space at the 2nd intercostal space along the mid clavicular line. The use of an 8-cm angiocatheter may be required at the 4th or 5th intercostal insertion site at the anterior axillary line. Novel decompression devices have been studied in animal models with improved success rates and quicker time to restoration of normal physiology. Devices described in this review include the modified Veress needle and the Reactor™ device. Human clinical trials are needed to confirm the safety and efficacy of these devices for clinical use.
Objective:
Life-threatening thoracic trauma requires emergency pleural decompression and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children can be challenging. We assessed whether the Mid-Arm Point (MAP) technique, a procedural aid proposed for use with injured adults, would also identify a safe site for pleural decompression in children.
Methods:
Children (0-18 years) attending four EDs were prospectively recruited. The MAP technique was performed, and chest wall skin marked bilaterally at the level of the MAP; no pleural decompression was performed. Radio-opaque markers were placed over the MAP-determined skin marks and corresponding intercostal space (ICS) reported using chest X-ray.
Results:
A total of 392 children participated, and 712 markers sited using the MAP technique were analysed. Eighty-three percentage of markers were sited within the 'safe zone' for pleural decompression (4th to 6th ICSs). When sited outside the 'safe zone', MAP-determined markers were typically too caudal. However, if the site for pleural decompression was transposed one ICS cranially in children ≥4 years, the MAP technique performance improved significantly with 91% within the 'safe zone'.
Conclusions:
The MAP technique reliably determines a safe site for pleural decompression in children, albeit with an age-based adjustment, the Mid-Arm Point in PAEDiatrics (MAPPAED) rule: 'in children aged ≥4 years, use the MAP and go up one ICS to hit the safe zone. In children <4 years, use the MAP.' When together with this rule, the MAP technique will identify a site within the 'safe zone' in 9 out of 10 children.
Background
Needle thoracostomy (NT) is the first-line intervention for tension pneumothorax in the prehospital setting. This study examined the effect of ATLS curriculum and EMS protocol changes on patient selection and successful performance of the procedure.
Methods
This is a retrospective chart review of all patients presenting to a Level One Trauma Center from 2015-2020 after undergoing prehospital NT.
Results
Lateral NT placement increased significantly from 5.1% to 38.9%. Proper patient selection, defined as presence decompensated shock, respiratory distress, and diminished breath sounds increased from 23.1% to 27.8%. There was no difference in radiographic confirmation of the catheter in the pleural space. Iatrogenic injury rates decreased slightly from 28.2% to 16.7%.
Conclusions
Protocol and curriculum changes have fallen short in yielding improved NT success rates or patient selection. Continued development of EMS education on the performance of NT is indicated.
For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax.
Chest trauma accounts for 25% of trauma deaths. Penetrating thoracic injuries occur most commonly from gunshot wounds and stab wounds, while motor vehicle collisions account for the majority of blunt thoracic injuries. Resuscitative emergency department thoracotomy may be indicated in patients with thoracic trauma who arrive in traumatic circulatory arrest depending on the duration of arrest time and whether signs of life are present on arrival. For chest trauma patients not in circulatory arrest, resuscitation begins with the primary survey which identifies life-threatening injuries that require immediate intervention. These injuries include airway obstruction, tracheobronchial tree injury, tension or open pneumothorax, massive hemothorax, and cardiac tamponade. Primary survey adjuncts including laboratory values, chest radiograph, and focused assessment with sonography in trauma exam with additional thoracic ultrasound views aid in identification of injuries. The secondary survey includes a head-to-toe physical exam, focused history and additional imaging including computed tomography (often with angiography). Additional thoracic injuries identified during the primary and secondary survey include flail chest, pulmonary contusion, blunt cardiac injury, traumatic aortic disruption, diaphragm disruption, and esophageal rupture.KeywordsPenetratingThoracicTraumaBluntResuscitationResuscitative thoracotomyTube thoracostomyNeedle thoracostomy
Importance:
Prehospital needle decompression (PHND) is a rare but potentially life-saving procedure. Prior studies on chest decompression in trauma patients have been small, limited to single institutions or emergency medical services (EMS) agencies, and lacked appropriate comparator groups, making the effectiveness of this intervention uncertain.
Objective:
To determine the association of PHND with early mortality in patients requiring emergent chest decompression.
Design, setting, and participants:
This was a retrospective cohort study conducted from January 1, 2000, to March 18, 2020, using the Pennsylvania Trauma Outcomes Study database. Patients older than 15 years who were transported from the scene of injury were included in the analysis. Data were analyzed between April 28, 2021, and September 18, 2021.
Exposures:
Patients without PHND but undergoing tube thoracostomy within 15 minutes of arrival at the trauma center were the comparison group that may have benefited from PHND.
Main outcomes and measures:
Mixed-effect logistic regression was used to determine the variability in PHND between patient and EMS agency factors, as well as the association between risk-adjusted 24-hour mortality and PHND, accounting for clustering by center and year. Propensity score matching, instrumental variable analysis using EMS agency-level PHND proportion, and several sensitivity analyses were performed to address potential bias.
Results:
A total of 8469 patients were included in this study; 1337 patients (11%) had PHND (median [IQR] age, 37 [25-52] years; 1096 male patients [82.0%]), and 7132 patients (84.2%) had emergent tube thoracostomy (median [IQR] age, 32 [23-48] years; 6083 male patients [85.3%]). PHND rates were stable over the study period between 0.2% and 0.5%. Patient factors accounted for 43% of the variation in PHND rates, whereas EMS agency accounted for 57% of the variation. PHND was associated with a 25% decrease in odds of 24-hour mortality (odds ratio [OR], 0.75; 95% CI, 0.61-0.94; P = .01). Similar results were found in patients who survived their ED stay (OR, 0.68; 95% CI, 0.52-0.89; P < .01), excluding severe traumatic brain injury (OR, 0.65; 95% CI, 0.45-0.95; P = .03), and restricted to patients with severe chest injury (OR, 0.72; 95% CI, 0.55-0.93; P = .01). PHND was also associated with lower odds of 24-hour mortality after propensity matching (OR, 0.79; 95% CI, 0.62-0.98; P = .04) when restricting matches to the same EMS agency (OR, 0.74; 95% CI, 0.56-0.99; P = .04) and in instrumental variable probit regression (coefficient, -0.60; 95% CI, -1.04 to -0.16; P < .01).
Conclusions and relevance:
In this cohort study, PHND was associated with lower 24-hour mortality compared with emergent trauma center chest tube placement in trauma patients. Although performed rarely, PHND can be a life-saving intervention and should be reinforced in EMS education for appropriately selected trauma patients.
Penetrating injuries account for nearly 10% of trauma cases with nearly 30% of these involving the chest. All trauma patients should be expeditiously assessed with the primary survey in a systematic fashion including airway, breathing, and circulation. Since penetrating thoracic trauma can affect each of the ABCs, there are several intrathoracic pathologies that need to be recognized immediately during the primary survey as there may be a lifesaving intervention that can be offered. These include pneumothorax, hemothorax, cardiac, lung, and esophageal injuries. This chapter will focus on the recognition of intrathoracic pathology after penetrating trauma as well as the interventions that are available.KeywordsThoracotomyHemopneumothoraxGreat vesselCardiacLungTracheobronchialEsophageal
Fracture-related infection (FRI) is a serious complication after fracture fixation and imposes a considerable burden on patients and health care providers. Polytraumatized patients are at high risk of developing an FRI since severe trauma is commonly accompanied by complex musculoskeletal injuries and a compromised host immune response. In this chapter, we provide a comprehensive summary of recent consensus recommendations on diagnostic and treatment principles for FRI.An FRI can be definitively diagnosed in the presence of at least one of the five confirmatory criteria. The presence of suggestive criteria requires further investigations in order to look for confirmatory criteria. The surgical strategies of FRI treatment are debridement, antimicrobial therapy, and implant retention (DAIR) or implant removal/exchange. The two main antimicrobial goals are infection eradication or—in selected cases—infection suppression until fracture union is achieved.Successful diagnosis and treatment of an FRI requires a multidisciplinary team approach, or transfer of the patient to a specialized bone infection center.KeywordsFracture-related infectionOsteomyelitisAntimicrobial therapyDiagnostic criteriaFractureInfection
This paper presents a three-dimensional nonlinear biomechanical finite element model to simulate elderly breast deformation under arm abduction. The finite element model was constructed based on complex anatomical structures that consist of the soft tissues including torso, breast, pectoralis major muscle, and rigid bones including humerus, sternum, clavicle and ribs. The elderly breast was defined as material nonlinearity and geometric nonlinearity. The computational model can simulate and illustrate the deformation of soft tissues during arm abduction from 30° to 90°. The finite element model was validated by motion data. The Young’s modulus for the clavicular portion and the sternocostal portion of the pectoralis major muscle was characterized as 0.1 MPa and 0.08 MPa, respectively. Besides this, the finite element model presented here features the musculoskeletal system for breast deformation and reveals the synergistic relationship between the breast and the pectoralis major muscle. A questionnaire was conducted to analyze the importance of purchasing factors and the discomfort positions in a sports bra from the perspective of senior women. Combined with the finite element model results, this study provides a promising basis for the design of sports bras in an ergonomic way.
Zusammenfassung
Häufig sind thorakale Verletzungen Begleitverletzungen im Rahmen eines Polytraumas. Die Therapie polytraumatisierter Patienten ist anspruchsvoll und nur im interdisziplinären Kontext erfolgversprechend. Aus thoraxchirurgischer Sicht steht dabei das stumpfe Thoraxtrauma im Vordergrund.
Purpose of review:
European Resuscitation Council Guidelines for Cardiopulmonary Resuscitation prioritize treatments like chest compression and defibrillation, known to be highly effective for cardiac arrest from cardiac origin. This review highlights the need to modify this approach in special circumstances.
Recent findings:
Potentially reversible causes of cardiac arrest are clustered into four Hs and four Ts (Hypoxia, Hypovolaemia, Hyperkalaemia/other electrolyte disorders, Hypothermia, Thrombosis, Tamponade, Tension pneumothorax, Toxic agents). Point-of-care ultrasound has its role in identification of the cause and targeting treatment. Time-critical interventions may even prevent cardiac arrest if applied early. The extracorporeal CPR (eCPR) or mechanical CPR should be considered for bridging the period needed to reverse the precipitating cause(s). There is low quality of evidence available to guide the treatment in the majority of situations. Some topics (pulmonary embolism, eCPR, drowning, pregnancy and opioid toxicity) were included in recent ILCOR reviews and evidence updates but majority of recommendations is based on individual systematic reviews, scoping reviews, evidence updates and expert consensus.
Summary:
Cardiac arrests from reversible causes happen with lower incidence. Return of spontaneous circulation and neurologically intact survival can hardly be achieved without a modified approach focusing on immediate treatment of the underlying cause(s) of cardiac arrest.
Background
Pneumothorax (PTX) is defined as air in the pleural space and is classified as spontaneous or nonspontaneous (traumatic). Traumatic PTX is a common pathology identified in the emergency department. Traditional management calls for chest x-ray (CXR) diagnosis and large-bore tube thoracostomy, although recent literature supports the efficacy of lung ultrasound (US) and more conservative approaches. There is a paucity of cohesive literature on how to best manage the traumatic PTX.
Objective of the Review
This review aimed to describe current practices and future directions of traumatic PTX management.
Discussion
Lung US has proven to be a potentially more useful tool in the detection of PTX in the trauma bay compared with CXR, and has the potential to become the new gold standard for diagnosing traumatic PTX. Computed tomography remains the ultimate gold standard, although in the setting of trauma, its utility lies more in confirming the presence and measuring the size of a PTX. The traditional mantra calling for large-bore chest tubes as first-line approaches to traumatic PTX is challenged by recent literature demonstrating pigtail catheters as equally efficacious alternatives. In patients with small or occult PTXs, even observation may be reasonable.
Conclusions
Modern management of the traumatic PTX is shifting toward use of US for diagnosis and more conservative management practices (smaller catheters or observation). Ultimately, this shift is favorable in reducing length of stay, development of complications, and pain in the trauma patient.
Background
Traumatic tension pneumothoraces (TPT) are among the most serious causes of death in traumatic injuries, requiring immediate treatment with a needle thoracostomy (NT). Improperly placed NT insertion into the pleural cavity may fail to treat a life-threatening TPT. This study aimed to assess the accuracy of prehospital NT placements by paramedics in adult trauma patients.
Methods
A retrospective chart review was performed on 84 consecutive trauma patients who had received NT by prehospital personnel. The primary outcome was the accuracy of NT placement by prehospital personnel. Comparisons of various variables were conducted between those who survived and those who died, and proper versus improper needle insertion separately.
Results
Proper NT placement into the pleural cavity was noted in 27.4% of adult trauma patients. In addition, more than 19% of the procedures performed by the prehospital providers appeared to have not been medically indicated.
Discussion
Long-term strategies may be needed to improve the capabilities and performance of prehospital providers’ capabilities in this delicate life-saving procedure.
Level of evidence
IV.
Objective:
To determine whether the reported clinical presentation of tension pneumothorax differs between patients who are breathing unassisted versus receiving assisted ventilation.
Background:
Animal studies suggest that the pathophysiology and physical signs of tension pneumothorax differ by subject ventilatory status.
Methods:
We searched electronic databases through to October 15, 2013 for observational studies and case reports/series reporting clinical manifestations of tension pneumothorax. Two physicians independently extracted clinical manifestations reported at diagnosis.
Results:
We identified 5 cohort studies (n = 310 patients) and 156 case series/reports of 183 cases of tension pneumothorax (n = 86 breathing unassisted, n = 97 receiving assisted ventilation). Hypoxia was reported among 43 (50.0%) cases of tension pneumothorax who were breathing unassisted versus 89 (91.8%) receiving assisted ventilation (P < 0.001). Pulmonary dysfunction progressed to respiratory arrest in 9.3% of cases breathing unassisted. As compared to cases who were breathing unassisted, the adjusted odds of hypotension and cardiac arrest were 12.6 (95% confidence interval, 5.8-27.5) and 17.7 (95% confidence interval, 4.0-78.4) times higher among cases receiving assisted ventilation. One cohort study reported that none of the patients with tension pneumothorax who were breathing unassisted versus 39.6% of those receiving assisted ventilation presented without an arterial pulse. In contrast to cases breathing unassisted, the majority (70.4%) of those receiving assisted ventilation who experienced hypotension or cardiac arrest developed these signs within minutes of clinical presentation.
Discussion:
The reported clinical presentation of tension pneumothorax depends on the ventilatory status of the patient. This may have implications for improving the diagnosis and treatment of this life-threatening disorder.
Objectives:
Needle decompression of tension pneumothorax in soldiers of the French infantry has a risk for failure when the standard procedure that involves the insertion of a 14-gauge, 5-cm catheter into the 2nd intercostal space (ICS) is used. This study measured the chest wall thickness (CWT) to assess whether this approach is appropriate.
Methods:
CWT was measured by ultrasound in 122 French soldiers at the 2nd and 4th ICSs on both the right and left sides.
Results:
CWT was measured at 4.19 cm (± 0.96 cm) at the 2nd ICS and 3.00 cm (± 0.91 cm) at the 4th ICS (p < 0.001). CWT was greater than 5 cm in 24.2% of cases at the 2nd ICS and 4.9% of cases at the 4th ICS (p < 0.001).
Conclusions:
This study suggests a high risk of failure when using the technique currently taught in the French army. A lateral approach into the 4th ICS could decrease this risk. The results of this study must be validated in patients presenting tension pneumothorax.
Needle decompression of a tension pneumothorax can be a lifesaving procedure. It requires an adequate needle length to reach the chest wall to rapidly remove air. With adult obesity exceeding one third of the United States population in 2010, we sought to evaluate the proper catheter length that may result in a successful needle decompression procedure. Advance Trauma Life Support (ATLS) currently recommends a 51 millimeter (mm) needle, while the needles stocked in our emergency department are 46 mm. Given the obesity rates of our patient population, we hypothesize these needles would not have a tolerable success rate of 90%.
We retrospectively reviewed 91 patient records that had computed tomography of the chest and measured the chest wall depth at the second intercostal space bilaterally.
We found that 46 mm needles would only be successful in 52.7% of our patient population, yet the ATLS recommended length of 51 mm has a success rate of 64.8%. Therefore, using a 64 mm needle would be successful in 79% percent of our patient population.
Use of longer length needles for needle thoracostomy is essential given the extent of the nation's adult obesity population.
Objective To compare the distance to be traversed during needle thoracostomy decompression performed at the second intercostal space (ICS) in the midclavicular line (MCL) with the fifth ICS in the anterior axillary line (AAL).
Design Patients were separated into body mass index (BMI) quartiles, with BMI calculated as weight in kilograms divided by height in meters squared. From each BMI quartile, 30 patients were randomly chosen for inclusion in the study on the basis of a priori power analysis (n = 120). Chest wall thickness on computed tomography at the second ICS in the MCL was compared with the fifth ICS in the AAL on both the right and left sides through all BMI quartiles.
Setting Level I trauma center.
Patients Injured patients aged 16 years or older evaluated from January 1, 2009, to January 1, 2010, undergoing computed tomography of the chest.
Results A total of 680 patients met the study inclusion criteria (81.5% were male and mean age was 41 years [range, 16-97 years]). Of the injuries sustained, 13.2% were penetrating, mean (SD) Injury Severity Score was 15.5 (10.3), and mean BMI was 27.9 (5.9) (range, 15.4-60.7). The mean difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL was 12.9 mm (95% CI, 11.0-14.8; P < .001) on the right and 13.4 mm (95% CI, 11.4-15.3; P < .001) on the left. There was a stepwise increase in chest wall thickness across all BMI quartiles at each location of measurement. There was a significant difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL in all quartiles on both the right and the left. The percentage of patients with chest wall thickness greater than the standard 5-cm decompression needle was 42.5% at the second ICS in the MCL and only 16.7% at the fifth ICS in the AAL.
Conclusions In this computed tomography–based analysis of chest wall thickness, needle thoracostomy decompression would be expected to fail in 42.5% of cases at the second ICS in the MCL compared with 16.7% at the fifth ICS in the AAL. The chest wall thickness at the fifth ICS AAL was 1.3 cm thinner on average and may be a preferred location for needle thoracostomy decompression.
Needle aspiration is a recognised emergency treatment of spontaneous pneumothorax and in the case of suspected tension is usually performed before chest radiography. Three cases are described of apparent life threatening haemorrhage after anterior aspiration in the second intercostal space, mid-clavicular line (2ICS MCL) requiring resuscitation, and transfer to a cardiothoracic unit. In these patients there was no evidence of haemothorax on initial presentation. Lateral needle aspiration, in the site recommended for chest drain insertion, the 5th intercostal space, anterior axillary line (5ICS ALL) is technically easy and may be a potentially safer option for decompressing pneumothoraces.
Invasive practical procedures require identification of surface anatomical landmarks to reduce risk of damage to other structures. Needle thoracocentesis has specific complications, which have been previously documented. An observational study was performed among emergency physicians to name the landmark for needle thoracocentesis and identify this point on a human volunteer as per Advanced Trauma and Life Support (ATLS) guidelines.
A cohort of 25 emergency physicians was studied, 21 (84%) of which were ATLS certified. The correct landmark was named by 22 (88%). Only 15 (60%) correctly identified the second intercostal space on the human volunteer, all placing the needle medial to the midclavicular line, with a range of 3 cm. Two (8%) named and identified the site of needle pericardiocentesis; one (4%) named and identified the fifth intercostal space in the anterior axillary line.
These results demonstrate a low accuracy among emergency physicians in identifying correct landmarks for needle thoracocentesis under elective conditions. Should greater emphasis be placed on competency based training in ATLS?
Introduction Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis.
A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness.
The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm. Discussion A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence. Clemency BM , Tanski CT , Rosenberg M , May PR , Consiglio JD , Lindstrom HA . Sufficient catheter length for pneumothorax needle decompression: a meta-analysis. Prehosp Disaster Med. 2015;30(3):1 5.
Five-centimeter needles at the second intercostal space midclavicular line (2MCL) have high failure rates for decompression of tension pneumothorax. This study evaluates 8-cm needles directed at the fourth intercostal space anterior axillary line (4AAL).
Retrospective radiographic analysis of 100 consecutive trauma patients 18 years or older from January to September 2011. Measurements of chest wall thickness (CWT) and depth to vital structure (DVS) were obtained at 2MCL and 4AAL. 4AAL measurements were taken based on two angles: closest vital structure and perpendicular to the chest wall. Primary outcome measures were radiographic decompression (RD) (defined as CWT < 80 mm) and radiographic noninjury (RNI) (DVS > 80 mm) of 8-cm needles at 4AAL. Secondary outcome measures are effect of angle of entry on RNI at 4AAL, RD and RNI of 8-cm needles at 2MCL, and comparison of 5-cm needles with 8-cm needles at both locations.
Eighty-four percent of the patients were male, with mean Injury Severity Score (ISS) of 17.7 (range, 1.0-66.0) and body mass index of 26.8 (16.5-48.4). Mean CWT at 4AAL ranged from 37.6 mm to 39.9 mm, significantly thinner than mean CWT at 2MCL (43.3-46.7 mm). Eight-centimeter needle RD was more than 96% at both 4AAL and 2MCL. Five-centimeter RD ranged from 66% to 81% at all sites. Mean DVS at 4AAL ranged from 91.8 mm to 128.0 mm. RNI at all sites was more than 91% except at left 4AAL, when taken to the closest vital structure (mean DVS, 91.8 mm), with 68% RNI. Perpendicular entry increased DVS to 109.4 mm and subsequent RNI to 91%. Five-centimeter RNI at all sites was more than 99%.
CWT at 4AAL is significantly thinner than 2MCL. Based on radiographic measurements, 8-cm catheters have a higher chance of pleural decompression when compared with 5-cm catheters. Steeper angle of entry at 4AAL improves 8-cm noninjury rates to more than 91%.
Therapeutic/care management study, level IV.
Obesity increases the incidence of mortality in trauma patients. Current Advanced Trauma Life Support guidelines recommend using a 5-cm catheter at the second intercostal (ICS) space in the mid-clavicular line to treat tension pneumothoraces. Our study purpose was to determine whether body mass index (BMI) predicted the catheter length needed for needle thoracostomy.
We retrospectively reviewed trauma patients undergoing chest computed tomography scans January 2004 through September 2006. A BMI was calculated for each patient, and the chest wall thickness (CWT) at the second ICS in the mid-clavicular line was measured bilaterally. Patients were grouped by BMI as underweight (≤18.5kg/m2), normal weight (18.6-24.9kg/m(2)), overweight (25-29.9kg/m(2)), or obese (≥30kg/m(2)).
Three hundred twenty-six patients were included in the study; 70% were male. Ninety-four percent of patients experienced blunt trauma. Sixty-three percent of patients were involved in a motor vehicle collision. The average BMI was 29 [SD 7.8]. The average CWT was 6.2 [SD 1.9]cm on the right and 6.3 [SD 1.9]cm on the left. As BMI increased, a statistically significant (p<0.0001) CWT increase was observed in all BMI groups. There were no significant differences in ISS, ventilator days, ICU length of stay, or overall length of stay among the groups.
As BMI increases, there is a direct correlation to increasing CWT. This information could be used to quickly select an appropriate needle length for needle thoracostomy. The average patient in our study would require a catheter length of 6-6.5cm to successfully decompress a tension pneumothorax. There are not enough regionally available data to define the needle lengths needed for needle thoracostomy. Further study is required to assess the feasibility and safety of using varying catheter lengths.
Background:
Needle thoracostomy is the emergent treatment for tension pneumothorax. This procedure is commonly done using a 4.5cm catheter, and the optimal site for chest wall puncture is controversial. We hypothesize that needle thoracostomy cannot be performed using this catheter length irrespective of the site chosen in either gender.
Methods:
A retrospective review of all chest computed tomography (CT) scans obtained on trauma patients from January 1, 2011 to December 31, 2011 was performed. Patients aged 18 and 80 years were included and patients whose chest wall thickness exceeded the boundary of the images acquired were excluded. Chest wall thickness was measured at the 2nd intercostal (ICS), midclavicular line (MCL) and the 5th ICS, anterior axillary line (AAL). Injury severity score (ISS), chest wall thickness, and body mass index (BMI) were analyzed.
Results:
201 patients were included, 54% male. Average (SD) BMI was 26 (7)kg/m(2). The average chest wall thickness in the overall cohort was 4.08 (1.4)cm at the 2nd ICS/MCL and 4.55 (1.7)cm at the 5th ICS/AAL. 29% of the overall cohort (27 male and 32 female) had a chest wall thickness greater than 4.5cm at the 2nd ICS/MCL and 45% (54 male and 36 female) had a chest wall thickness greater than 4.5cm at the 5th ICS/AAL. There was no significant interaction between gender and chest wall thickness at either site. BMI was positively associated with chest wall thickness at both the 2nd and 5th ICS/AAL.
Conclusion:
A 4.5cm catheter is inadequate for needle thoracostomy in most patients regardless of puncture site or gender.
Background:
Excess bodyweight is a major public health concern. However, few worldwide comparative analyses of long-term trends of body-mass index (BMI) have been done, and none have used recent national health examination surveys. We estimated worldwide trends in population mean BMI.
Methods:
We estimated trends and their uncertainties of mean BMI for adults 20 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (960 country-years and 9·1 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean BMI by age, country, and year, accounting for whether a study was nationally representative.
Findings:
Between 1980 and 2008, mean BMI worldwide increased by 0·4 kg/m(2) per decade (95% uncertainty interval 0·2-0·6, posterior probability of being a true increase >0·999) for men and 0·5 kg/m(2) per decade (0·3-0·7, posterior probability >0·999) for women. National BMI change for women ranged from non-significant decreases in 19 countries to increases of more than 2·0 kg/m(2) per decade (posterior probabilities >0·99) in nine countries in Oceania. Male BMI increased in all but eight countries, by more than 2 kg/m(2) per decade in Nauru and Cook Islands (posterior probabilities >0·999). Male and female BMIs in 2008 were highest in some Oceania countries, reaching 33·9 kg/m(2) (32·8-35·0) for men and 35·0 kg/m(2) (33·6-36·3) for women in Nauru. Female BMI was lowest in Bangladesh (20·5 kg/m(2), 19·8-21·3) and male BMI in Democratic Republic of the Congo 19·9 kg/m(2) (18·2-21·5), with BMI less than 21·5 kg/m(2) for both sexes in a few countries in sub-Saharan Africa, and east, south, and southeast Asia. The USA had the highest BMI of high-income countries. In 2008, an estimated 1·46 billion adults (1·41-1·51 billion) worldwide had BMI of 25 kg/m(2) or greater, of these 205 million men (193-217 million) and 297 million women (280-315 million) were obese.
Interpretation:
Globally, mean BMI has increased since 1980. The trends since 1980, and mean population BMI in 2008, varied substantially between nations. Interventions and policies that can curb or reverse the increase, and mitigate the health effects of high BMI by targeting its metabolic mediators, are needed in most countries.
Funding:
Bill & Melinda Gates Foundation and WHO.
Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate.
Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position.
A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008).
In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.
Recent research describes failed needle decompression in the anterior position. It has been hypothesized that a lateral approach may be more successful. The aim of this study was to identify the optimal site for needle decompression.
A retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides.
The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces (p < 0.01).
With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.
Background:
Previous studies reported a high failure rate in relieving tension pneumothorax by needle thoracostomy, because the catheter was not sufficiently long to access the pleural space. The Advanced Trauma Life Support guideline recommends needle thoracostomy at the second intercostal space in the middle clavicular line using a 5.0-cm catheter, whereas the corresponding guideline in Japan does not mention a catheter length. It is necessary to measure the chest wall thickness (CWT) and determine the appropriate catheter length taking the differences of habitus in race and region into consideration. This study was designed to analyse CWT in Japanese trauma patients by computed tomography and to determine the percentage of patients whose pleural space would be accessible using a 5.0-cm catheter.
Patients and methods:
We performed a retrospective review of chest computed tomography of 256 adult Japanese trauma patients who were admitted to the level 1 trauma centre of Tokai University Hospital in Kanagawa, Japan between January and July 2008. In 256 patients, the CWT at 512 sites (left and right sides) was measured by chest computed tomography at the second intercostal space in the middle clavicular line. The frequency of measurement sites <5.0 cm was calculated simultaneously. The samples were divided according to gender, side (left and right), abbreviated injury scale (<3, ≧3), arm position during examination (up/down), and the existence or non-existence of associated injuries (pneumothorax, subcutaneous emphysema, and fracture of the sternum and ribs); the CWT of each group was compared.
Results:
The mean CWT measured in 192 males and 64 females was 3.06±1.02 cm. The CWT values at 483 sites (94.3%) were less than 5.0 cm. The CWT of females was significantly greater than that of males (3.66 cm vs. 2.85 cm, p<0.0001), and patients with subcutaneous emphysema had greater CWTs than those without it (4.16 cm vs. 3.01 cm, p<0.0001).
Conclusion:
The mean CWT at the second intercostal space in the middle clavicular line was 3.06 cm. It is likely that over 94% of Japanese trauma patients could be treated with a 5.0-cm catheter.
Computed tomography measurements of chest wall thickness (CWT) suggest that standard-length angiocatheters (4.5 cm) may fail to decompress tension pneumothoraces. We used an alternative modality, ultrasound, to measure CWT. We correlated CWT with body mass index (BMI) and used national data to estimate the percentage of patients with CWT greater than 4.5 cm.
This was an observational, cross-sectional study of a convenience sample. We recorded standing height, weight, and sex. We measured CWT with ultrasound at the second intercostal space, midclavicular line and at the fourth intercostal space, midaxillary line on supine subjects. We correlated BMI (weight [in kilograms]/height(2) [in square meters]) with CWT using linear regression. 95% Confidence intervals (CIs) assessed statistical significance. National Health and Nutrition Examination Survey results for 2007-2008 were combined to estimate national BMI adult measurements.
Of 51 subjects, 33 (65%) were male and 18 (35%) were female. Mean anterior CWT (male, 2.1 cm; CI, 1.9-2.3; female, 2.3 cm; CI, 1.7-2.7), lateral CWT (male, 2.4 cm; CI, 2.1-2.6; female, 2.5 cm; CI 2.0-2.9), and BMI (male, 27.7; CI, 26.1-29.3; female, 30.0; CI, 25.8-34.2) did not differ by sex. Lateral CWT was greater than anterior CWT (0.2 cm; CI, 0.1-0.4; P < .01). Only one subject with a BMI of 48.2 had a CWT that exceeded 4.5 cm. Using national BMI estimates, less than 1% of the US population would be expected to have CWT greater than 4.5 cm.
Ultrasound measurements suggest that most patients will have CWT less than 4.5 cm and that CWT may not be the source of the high failure rate of needle decompression in tension pneumothorax.
Tension pneumothorax can lead to cardiovascular collapse and death. In the prehospital setting, needle thoracostomy for emergent decompression may be lifesaving. Taught throughout the United States to emergency medical technicians (EMTs) and physicians, the true efficacy of this procedure is unknown. Some question the utility of this procedure in the prehospital setting, doubting that the needle actually enters the pleural space. This study was designed to determine if needle decompression of a suspected tension pneumothorax would access the pleural cavity as predicted by chest computed tomography (CT).
We retrospectively reviewed consecutive adult trauma patients admitted to a level I trauma center between January and March 2005. We measured chest wall depth at the second intercostal space, midclavicular line on CT scans. Data on chest wall thickness were compared with the standard 4.4-cm angiocatheter used for needle decompression.
Data from 110 patients were analyzed. The mean age of the patients was 43.5 years. The mean chest wall depth on the right was 4.5 cm (+/- 1.5 cm) and on the left was 4.1 cm (+/- 1.4 cm). Fifty-five of 110 patients had at least one side of the chest wall measuring greater than 4.4 cm.
The standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7-59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration.
Advanced Trauma Life Support guidelines recommend the use of a cannula 3 to 6 cm long to perform needle thoracocentesis for life-threatening tension pneumothorax. The chest wall thickness in the 2nd intercostal space, mid-clavicular line, was determined by ultrasound in 54 patients aged 18 to 55 years, and ranged from 1.3 to 5.2 cm (mean 3.2 cm). In thirty-one patients (57 per cent) the chest-wall thickness (CWT) was greater than 3 cm, the minimum recommended cannula length, although in only two (4 per cent) was it greater than 4.5 cm, the length of cannula commonly used in the UK. As a 3 cm cannula would fail to reach the pleural cavity in over half of patients, we suggest that the recommended shortest length be increased to 4.5 cm. Unsuccessful needle thoracocentesis using a 4.5 cm cannula should be followed immediately by insertion of a longer cannula or a definitive chest drain.
To determine the length of catheter required to perform a needle thoracostomy, as determined by chest wall thickness, to treat the majority of patients presenting to the emergency department (ED) with a potential tension pneumothorax.
A convenience sample of 111 computed tomography (CT) scans of the chest in trauma and medical resuscitation patients at a military Level 1 trauma center in San Antonio, Texas, was pooled, and the chest wall thickness was measured at the second intercostal space, midclavicular line, to the nearest 0.1 cm.
The mean chest wall thickness in the patients studied averaged 4.24 cm (95% confidence interval [CI] = 3.97 to 4.52). Nearly one fourth (25) of the study patients had a chest wall thicker than 5 cm. Women, on average, have thicker chest walls than men (4.90 for women; 4.16 for men; p = 0.022).
In this study, a catheter length of 5 cm would reliably penetrate the pleural space of only 75% of patients. A longer catheter should be considered, especially in women.
The recommended treatment of suspected tension pneumothorax is immediate needle decompression. Recommended sites and needle sizes for this procedure vary, and there are published reports of failed decompression as well as iatrogenic hemothorax. We investigated the optimal needle length and relative safety of three potential needle decompression sites.
Using thoracic computed tomography scans of 100 adults, we measured the distance from skin surface to pleura and to intrathoracic structures at the level of the sternal angle at the midhemithoracic line (MHL), and at the level of the xiphoid process at the anterior axillary and midaxillary lines, as well as the distance from the sternal midline to internal mammary vessels.
Median distances from the midline to the MHL and internal mammary vessels were 6.1 and 3.0 cm, respectively. Median (range) depth-to-pleura below the skin surface at the MHL, midaxillary lines, and anterior axillary line sites was 3.1 (1.4-6.9), 3.5 (1.7-9.3+), and 2.6 (1.0-7.7+) cm, respectively. Overall, there was a lower margin of safety on the left side compared with the right side, and the MHL site was safest on both sides.
Needle decompression of suspected tension pneumothorax should be attempted in the MHL at the level of the sternal angle using a needle at least 7 cm long inserted perpendicular to the horizontal plane. This approach should yield the highest success rate and margin of safety compared with other sites.
A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle.
To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces.
Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >/=40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL.
The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied.
A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.
Needle thoracentesis is an emergency procedure to relieve tension pneumothorax. Published recommendations suggest use of angiocatheters or needles in the 5-cm range for emergency treatment. Multidetector computed tomography scans from 100 virtual autopsy cases were used to determine chest wall thickness in deployed male military personnel. Measurement was made in the second right intercostal space at the midclavicular line. The mean horizontal thickness was 5.36 cm (SD = 1.19 cm) with angled (perpendicular) thickness slightly less with a mean of 4.86 cm (SD 1.10 cm). Thickness was generally greater than previously reported. An 8-cm angiocatheter would have reached the pleural space in 99% of subjects in this series. Recommended procedures for needle thoracentesis to relieve tension pneumothorax should be adapted to reflect use of an angiocatheter or needle of sufficient length.
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