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Three Part Question

In [patients with chest trauma], is [prehospital finger thoracostomy] a [safe and effective treatment for pneumothorax?]

Clinical Scenario

You attend the scene of a vehicle collision and find a 23 year old male unbelted in the drivers seat, slumped over the steering wheel unconscious. As the patient is rapidly extricated to the waiting ambulance, you note spidering of the windshield from the patient’s head and airbag deployment. Rapid ATLS exam reveals that the patient requires thoracostomy for a suspected tension pneumothorax. You have recently heard about finger thoracostomy as an alternative to needle decompression and wonder if this would be effective.

Search Strategy

PubMed 1950 to Feb 1st 2017
(Paramedic[Text Word]OR EMS[Text Word] OR Emergency Medical Services[Text Word] OR prehospital[Text Word]) AND trauma[Text Word] AND (finger thoracostomy[Text Word] OR simple thoracostomy[Text Word] OR thoracostomy[Text Word])

Google Scholar on Feb 1st 2017
(Paramedic OR EMS OR prehospital) AND (finger thoracostomy OR simple thoracostomy) In cases of discrepancy in data presented in any of the papers, the authors were contacted via email.

Search Outcome

2473 papers were identified on PubMed, of which 4 were directly relevant to the three part question.
5 papers contained related material but were excluded: 2 were specific to patients in cardiac arrest, and 3 were review articles.
1 additional paper was identified on Google Scholar that was directly relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Deakin et al 1995, UK	45 patients transported by HEMS with pneumothorax or hemothorax compromising ventilation, GCS less than/equal to 8, and requiring intubation for airway protection or ventilation. Patients treated with finger thoracostomy (FT).	Retrospective cohort	Clinical resolution judged by improved chest wall excursion and return of breath sounds	45/45 patients had immediate clinical resolution	Lack of detail for clinical definition of pneumothorax/hemothorax – reliance on chest wall excursion & auscultation in pre-hospital environment can be challenging. No additional vital sign parameters included in assessing ventilatory compromise. Patients were intubated prior to FT which may have contributed to some improvement in breath sounds & chest wall excursion or alternatively may have caused findings (right mainstem intubation mistaken for unilateral pneumothorax) Unblinded observation was used to collect data on infection rates
			Improvement on x-ray at arrival to hospital	45/45 patients had initial chest x-rays showing very minor residual pneumothorax or complete lung reexpansion
			Evidence of infection attributable to FT or subsequent chest tube insertion	0/45 patients
Massarutti et al 2006, Italy	55 patients transported by HEMS with thoracic trauma who underwent prehospital FT during the study period, excluding those in cardiac arrest. 59 procedures were performed on 55 patients (4 bilateral, 51 unilateral). Patients were sedated, intubated, and mechanically ventilated with 100% oxygen before FT.	Retrospective cohort	Improvement in SpO2	Mean SpO2 significantly improved after FT. Mean 86.4% +/- 10.2 before to 98.5% +/- 4.7 after, P<0.05	Study included policy for FT based on clinical signs, not requiring hypotension, severe dyspnea, or SpO2<90. This increased the number of patients treated and has the potential to over diagnosis pneumothorax. However FT was only performed in 3.4% of cases where there was no pneumothorax/hemothorax. Patients received multiple simultaneous interventions that may have affected their vital signs, including sedation/pain control, intubation and ventilation with 100% O2. 2 of 3 patients who died after ED arrival had no radiological investigations or autopsy and were determined to not have had tension pneumothorax recurrence by performance of finger sweep on ED arrival alone. No specific mention was made of contralateral investigations. Evaluation of pleural infections was conducted by chart review, not stated if reviewers were blinded.
			Improvement in BP	Improvement in hypotension was statistically significant. 19 (34.5%) of patients had SBP less than/equal to 90 before FT vs 7 (12.7%) after procedure, P<0.05
			Safety of finger thoracostomy	No patients had recurrent tension pneumothorax, missed injury with clinical signs at the time, major bleeding, lung laceration, pleural infection
Aylwin et al 2008 UK	35 patients transported by HEMS had 65 FT performed	Retrospective cohort	Complications associated with prehospital and inhospital procedures	Overall complication rate was 14%, with no deaths directly related to FT. 8/52 patients had major complications, all in patients with prehospital FT (2 hemothorax, 1 empyema, 1 scapular artery hemorrhage, 4 pneumothorax that retensioned). No wound site complications noted.	All patients received chest tube upon arrival to ED, regardless of findings. Complications for patients receiving prehospital FT were not analyzed separately, some complications were due to tube insertion in ED
Chesters et al 2016, UK	126 trauma patients transported by HEMS had 236 thoracostomies performed according to HEMS indications. 230/236 had FT, 6/236 had TT	Retrospective cohort. 51/126 were in cardiac arrest/periarrest 45/126 were considered high risk for developing pneumothorax because they were ventilated	SpO2 pre and post thoracostomy	In non-arrest patients mean SpO2 was 91.8% at team arrival and 97.2% at handover to ED, p=0.003	Improved SpO2 from team arrival to handover at ED cannot be attributed to thoracostomy alone as patients also received oxygenation and ventilation. SpO2 was only obtained on 38 patients for comparison and values temporal to the procedure were not utilized. Retrospective database collection may have resulted in missing data, including failure to report complications, and inability to obtain information on missing data (SpO2 not obtained due to hypotension, environment, or equipment failure)
			Immediate complications	No immediate complications noted
High et al 2016, USA	250 patients transported by Air Ambulance (fixed & rotor wing) who had TT or FT and were >18 years. 250 patients received a total of 421 TT/FT	Retrospective cohort, 87/250 were not in cardiac arrest 163/250 required CPR at scene	Clinical improvement in patients not in cardiac arrest	75/87 (86%) exhibited clinical improvement, the most common being increased ventilator compliance (68%)	Not exclusively trauma patients (2% were medical patients). No separation of data between FT and TT. Complications mostly noted to be tube related. Retrospective data collection from air medical records
			Complications	9/250 (3.6%) patients receiving thoracostomy had a complication. 1 (0.4%) had an empyema; the other 8 (3.2%) all had tubes dislodged during transport

Comment(s)

Finger thoracostomy has been implemented in some prehospital settings for patients who are not spontaneously breathing in response to concerns regarding the effectiveness of needle thoracostomy. The published studies varied in their inclusion of patients qualifying for thoracostomy. In the study by Massarutti et al, the programme expanded its protocol to include patients with decreased breath sounds, subcutaneous emphysema, serial rib fractures with chest wall instability, flail chest, and penetrating chest wounds regardless of vital signs. The authors found that for patients presenting with both SBP & SpO2 <90 before FT vs those with SBP & SpO2 >90 had a mean AIS thorax that was not statistically significant, however overall mortality was 61.6 vs 14.3% and ICU stay was 20.6 vs 12.9; the authors suggest that abnormal vital signs are an unreliable sign of tension pneumothorax and significant injury. This should be considered in future pre-hospital research to inform evidence based protocols. Determination of pneumothorax can be challenging in the pre-hospital environment. The studies relied on varying inclusion criteria and evidence of effectiveness that ranged from improved chest wall excursion to improved SpO2 to resolution on radiographic resolution. Together, they suggest that finger thoracotomy is effective at relieving pneumothorax, however future studies incorporating ultrasound in the prehospital diagnosis would be advantageous. Future high quality studies assessing the effectiveness and safety of finger thoracostomy by non-physician providers and, in particular, non HEMS personnel are required given the paucity of data in this setting.

Editor Comment

Abbreviations: HEMS Helicopter emergency medical service, FT finger thoracostomy, ED emergency department, TT tube thoracostomy

Note: Finger thoracostomy is used throughout for clarification, the papers reviewed utilized the terms finger thoracostomy, simple thoracostomy, or thoracostomy

Clinical Bottom Line

Finger thoracostomy in patients with chest trauma transported by HEMS crews is associated with improved clinical status and appears safe to perform in the prehospital environment. Further research is required to evaluate its use by non HEMS prehospital crews and non-physician providers.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Deakin, C.D.; Davies, G. & Wilson, A Simple Thoracostomy Avoids Chest Drain Insertion in Prehospital Trauma. J Trauma 1995;39:373–4.
2. Massarutti D , Trillò G , Berlot G , et al . Simple Thoracostomy in Prehospital Trauma Management is Safe and Effective: a 2-Year Experience by Helicopter Emergency Crews. Eur J Emerg Med 2006;13:276–80.
3. Aylwin CJ , Brohi K , Davies GD , et al . Pre-hospital and In-hospital Thoracostomy: Indications and Complications. Ann R Coll Engl 2008; 90, 54-57.
4. Chesters A , Davies G , Wilson A . Four Years of Pre-hospital Simple Thoracostomy Performed by a Physician-Paramedic Helicopter Emergency Medical Service Team. Trauma 2016; 18, 124-128.
5. High K , Brywczynski J , Guillamondegui O . Safety and Efficacy of Thoracostomy in the Air Medical Environment. Air Med J 2016; 35, 227-230.