Prehospital Chest Tube Thoracostomy

[Ace844]

Hi All,

I saw this and it made me wonder what you all thought....of the subject of pr-ehospital Chest tubes....

http://www.jtrauma.com/pt/re/jtrauma/abstr...9856145!9001!-1Prehospital Chest Tube Thoracostomy: Effective Treatment or Additional Trauma?

Prehospital Chest Tube Thoracostomy: Effective Treatment or Additional Trauma?

Journal of Trauma-Injury Infection & Critical Care. 59(1):96-101, July 2005.

Spanjersberg, Willem; Ringburg, Akkie; Bergs, Bert; Krijen, Pita; Schipper, Inger SP; Steyerberg, E W.; Edwards, M J.; Schipper, I B.; van Vugt, A B.

Abstract:

Background: The use of prehospital chest tube thoracostomy (TT) remains controversial because of presumed increased complication risks. This study analyzed infectious complication rates for physician-performed prehospital and emergency department (ED) TT.

Methods: Over a 40-month period, all consecutive trauma patients with TT performed by the flight physician at the accident scene were compared with all patients with TT performed in the emergency department. Bacterial cultures, blood samples, and thoracic radiographs were reviewed for TT-related infections.

Results: Twenty-two patients received prehospital TTs and 101 patients received ED TTs. Infected hemithoraces related to TTs were found in 9% of those performed in the prehospital setting and 12% of ED-performed TTs (not significant).

Conclusion: The prehospital chest tube thoracostomy is a safe and lifesaving intervention, providing added value to prehospital trauma care when performed by a qualified physician. The infection rate for prehospital TT does not differ from ED TT.

The Safety and Efficacy of Prehospital Needle and Tube Thoracostomy by Aeromedical Personnel

Daniel P. Davis A1, Kelly Pettit A1, Christopher D. Rom A1, Jennifer C. Poste A1, Michael J. Sise A1, David B. Hoyt A1, Gary M. Vilke A1

Abstract:

Background.Aeromedical crews routinely use needle thoracostomy (NT) and tube thoracostomy (TT) to treat major trauma victims (MTVs) with potential tension pneumothorax; however, the efficacy of prehospital NT and TT is unclear.Objectives.To explore the efficacy of aeromedical NT and TT in MTVs.Methods.A retrospective chart review was performed using prehospital medical records and the county trauma registry over a seven-year period. All MTVs undergoing placement of NT or TT by aeromedical personnel were included; patients with incomplete data were excluded. Descriptive statistics were used to report the incidence of air release, clinical improvement (improved breath sounds or compliance if intubated, decreased dyspnea if nonintubated), and vital signs improvements (systolic blood pressure [sBP] increase to ≥90 mm Hg or increase by 5 mm Hg if < 90 mm Hg; heart rate improvement to 60–100 beats/min, increase by 10 beats/min if < 60 BPM, or decrease by 10 beats/min if > 100 beats/min; oxygen saturation increase if < 95%) for both NT and TT as documented in prehospital medical records. Survival and improvement in SBP based on trauma registry data were recorded for patients stratified by initial SBP.Results.A total of 136 procedures (89 NTs and 47 TTs) in 81 patients were identified using prehospital medical records over a four-year period. Response rates to NT (60% overall, 32% vital signs) and TT (75% overall, 60% vital signs) were high. Vital signs improvements were observed more often in patients with a pulse and in nonintubated patients. A total of 168 patients were identified in the trauma registry over the seven-year study period. Normalization of SBP was observed in two-thirds of patients with a field SBP ≤ 90 mm Hg and one-third of patients in whom field SBP could not be obtained. A small but significant proportion of patients undergoing prehospital NT and TT, including some with prehospital hypotension and high injury severity, survived to hospital discharge. The incidence of complications was low.Conclusions.Aeromedical crews appear to appropriately select MTVs to undergo field NT or TT. A low incidence of complications and a small but significant group of unexpected survivors support continued use of this procedure by aeromedical personnel.Key words:aeromedical crews; trauma; needle thoracostomy; tube thoracostomy; survival; pneumothorax; efficacy.

Chest Tube Decompression of Blunt Chest Injuries by Physicians in the Field: Effectiveness and Complications.

Journal of Trauma-Injury Infection & Critical Care. 44(1):98-100, January 1998.

Schmidt, Ulf MD; Stalp, Michael MD; Gerich, Thorsten MD; Blauth, Michael MD; Maull, Kimball I. MD; Tscherne, Harald MD

Abstract:

Objective: Recent literature suggests that patients who undergo emergent tube thoracostomy in the field are at increased risks for complications. This study evaluates indications, complications, and effectiveness of field placement of chest tubes by an aeromedical service.

Methods: In a prospective study, 624 consecutive patients with chest injuries (Abbreviated Injury Scale score 1-6) were included. All patients were treated at the scene by a physician-staffed aeromedical service and transported by air to a Level I trauma center. Indications, clinical findings before and after chest tube insertion, and subsequent radiologic diagnosis by chest roentgenography were documented prospectively.Results: Seventy-six chest tubes (50 unilateral, 13 bilateral) were inserted laterally in 63 patients (10%) by blunt dissection. Clinical findings included pneumothorax in 30 patients and hemothorax in 18 patients. In 15 patients receiving field chest tubes, neither pneumothorax nor hemothorax was confirmed. Six patients (<1%) arrived at the trauma center with unsuspected pneumothoraces and required chest tube insertion. No tension pneumothoraces escaped field detection and treatment. Four chest tubes placed in the field required repositioning in the hospital because of malfunction or malpositioning. Radiologic findings excluded intraparenchymal tube placements in all patients. No pleural infections were observed in these 63 patients during their hospital stay. No antibiotics were administered as a result of prehospital chest tube placement.

Conclusion: Prehospital chest tube thoracostomy is safe, effective, and associated with low morbidity. Nontherapeutic chest tube placements occurred in 15 of 624 patients (2.4%); missed pneumothoraces occurred in 6 of 624 patients (<1%). Aggressive prehospital physician management of blunt chest trauma leads to an earlier treatment of potentially life-threatening injuries. Significant morbidity can be avoided by prompt pleural decompression using proper techniques

Hope this helps,

Ace844

[ERDoc]

Interesting study. Now someone needs to compare prehospital medic chest tubes and it may make it a benefit to the prehospital world (really, how many flight physicians are there really).

[Ace844]

Interesting study. Now someone needs to compare prehospital medic chest tubes and it may make it a benefit to the prehospital world (really, how many flight physicians are there really).

"ERdoc,"

Please see my "edited" post, I found one..As far as "flight physicians...I know that Umass uses them with a flight RN, and I don't know any others up this way.....perhaps other places they are more prevalent..?!!?!?

Hope this helps,

Ace844

[ERDoc]

"ERdoc,"

Please see my "edited" post, I found one..

I'm not impressed with the second absract (granted I'm only basing my opinion on the abstract and not the full article). The abstract does not say what the level of training was for these aeromedical crews (medics, nurses, MDs?). What country was this from (again, may account for different level of training)? I am also not impressed with doing a retrospective study from a trauma registry. How many people were excluded? What information was missing that caused them to be excluded? Would this information have changed the results of the study? A prospective study would need to be done to be of value.

[Ace844]

I'm not impressed with the second absract (granted I'm only basing my opinion on the abstract and not the full article). The abstract does not say what the level of training was for these aeromedical crews (medics, nurses, MDs?). What country was this from (again, may account for different level of training)? I am also not impressed with doing a retrospective study from a trauma registry. How many people were excluded? What information was missing that caused them to be excluded? Would this information have changed the results of the study? A prospective study would need to be done to be of value.

I agree with you, I posted it more to get an idea of what peoples opinions on this were and a "hey heads up" this may be coming type of scenario...I'll look into it further...I just don't have "online access to this journal.."

hope this helps,

Out here

[nsmedic393]

Our Critical Care flight medics, do thoracostomys under standing orders and have a great success rate.

[Guest]

we do not have standing orders for them here but they have been done in the field by medics with approval from on-line medical control in the past. Does not happen often at all in fact there has not been a chest tube in the field in at least ten yrs that i know of. But out comes were good according to the stories from the "old men" of the service.

[Nate]

To be honest, I don't think we have enough well trained medics in our area for services to start adopting this procedure.

[Dustdevil]

Our Critical Care flight medics, do thoracostomys under standing orders and have a great success rate.

How is success defined?

[Nate]

I know our local flight service Memorial Hermann's LifeFlight does them; but I'd be worried about letting PHI's SkyCrap touch my patient.