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Three Part Question

[In patients with traumatic cardiac arrest], is [prehospital finger thoracostomy] a [safe and effective treatment for presumed tension pneumothorax]?

Clinical Scenario

You are part of an EMS crew dispatched to the scene where a construction worker has fallen from a rooftop onto the concrete below. He was initially reported as combative when a basic life support crew arrived, and they now report that he has just lost vital signs. You quickly think about your ATLS approach to the trauma patient and wonder if a finger thoracostomy would be effective and safe in this environment to rule out tension pneumothorax as a cause of his arrest.

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 January 27, 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 3 were directly relevant to the three part question.
7 papers contained related material but were excluded: 4 were not specific to patients in cardiac arrest and 3 were review articles

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mistry et al 2009, UK	61 patientswere assessed by HEMS crews to have had a traumatic cardiac arrest (tCA). 37 of 61 received resuscitation attempts. Patients were excluded from the study if they had isolated head trauma, penetrating thoracic injuries mandating thoracotomy, or involved in hangings	Retrospective cohort, 18/37 patients with tCA that underwent resuscitation had chest decompression (1 needle thoracostomy,17 FT)	ROSC and cardiac activity at hospital arrival	4/18 patients had ROSC after thoracostomy	Retrospective data collection from records. Complication rate relied upon self report into database. Other procedures performed (intubation, ventilation, fluids) so effect of thoracostomy on ROSC cannot be isolated. 1 Needle thoracostomy included in analysis.
			Positive identification of pneumothorax/hemothorax	8/18 patients had tension pneumothorax/hemothorax
			Complications	No complications were reported
Peters et al 2017, Netherlands	All patients (pediatric and adult) treated by HEMS who had undergone a prehospital finger thoracostomy. 267 FT were performed on 144 patients in traumatic cardiac arrest (tCA) (123 bilateral)	Retrospective cohort	Rate of tension pneumothorax	14/144 (9.7%) patients in tCA had tension pneumothorax	Tension pneumothorax was defined as release of air under tension on incision combined with improved vital signs after thoracostomy. Complication rates were based off of 4 survivors, all received antibiotics. Retrospective database review, subject to missing data, failure to report sharps injury.
			ROSC	22/144 (15.3%) patients had ROSC after thoracostomy/ 6/22 (27.3%) had tension pneumothorax
			Survival	4/144 (2.8%) survived initial resuscitation in the ED; 2 survived to discharge home from hospital
			Complications	No complications noted on any patients who survived initial resuscitation
			Sharps injury to provider	No needle stick injuries reported
High et al 2016, USA	250 patients transported by Air Ambulance(fixed & rotor wing) who had tube (TT) or finger thoracostomy (FT) and were >18 years. 250 patients received a total of 421 TT/FT	Retrospective cohort 163/250 required CPR	Complications	1/163 (0.61%) patients requiring CPR that received thoracostomy survived	Not exclusively trauma patients (2% were medical patients). No separation of data between FT and TT, complications mainly tube related. Retrospective data collection from air medical records. No causes of death listed for nonsurvivors.
			Survival	9/250 (3.6%) patients total 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 pre-hospital settings for patients with chest trauma requiring decompression who are not spontaneously breathing or are in cardiac arrest. This has been in response to concerns regarding the effectiveness of needle thoracostomy. The low survival rate among patients in the study conducted by High et al reflects the poor outcomes for traumatic cardiac arrest, particularly blunt trauma, seen in the pre-hospital environment. No causes of death were listed for non-survivors so it was not possible to ascertain if the mortality rate was due to chest trauma or other non-survivable traumatic injuries, which would be unaffected by thoracostomy (ie, severe traumatic head injury). With specific reference to the effectiveness of finger thoracostomy, the study does not separate the two types of thoracostomy for further analysis. Most of the complications listed were due to tube dislodgement in transport, which would not be of concern for pre-hospital finger thoracostomy. In the study conducted by Mistry et al, tension pneumothorax or hemothorax was identified in 8/18 (44%) patients treated with thoracostomy and ROSC was obtained in 4/18 (22%) of patients after thoracostomy. Although no patients survived to discharge, all deaths were related to non-survivable head injury. They report a positive predictive value of thoracostomy performed for positive clinical signs of 1 (n=5/5), however the number of patients with confirmed pneumothorax is low overall. A lower rate of tension pneumothorax was seen in the study by Peters et al,3 however their definition required improvement in vital signs and a clinical description of air release under pressure to confirm the diagnosis, which can be challenging in the pre-hospital environment. For patients diagnosed with tension pneumothorax who did not have ROSC, the diagnosis was presumably based on air release alone. Unfortunately, there was no analysis of diagnosis of tension pneumothorax based on clinical signs or description of the specific criteria used to determine when a thoracostomy should be performed. Survival was again poor, 2.8% survived to the ICU and 1.4% to discharge. The two patients who survived to discharge were categorised as not having tension pneumothorax. It is unclear whether they had a missed diagnosis of relieved tension pneumothorax or whether other procedures such as fluid resuscitation, airway management, pelvic binding, and epinephrine administration contributed to their sustained ROSC. Given the anticipated low survival rate in patients found in traumatic cardiac arrest (0%–2.3%) (Peters et al), the studies likely underreport the success of relieving significant pneumothorax. Similarly, ROSC alone cannot be used as a marker for confirmation of pneumothorax when it is performed in the setting of other stabilising procedures such as intubation, ventilation, and fluid resuscitation. The use of ultrasound by pre-hospital providers may allow them to rapidly determine which patients would benefit from thoracostomy.

Editor Comment

Abbreviations: HEMS Helicopter emergency medical service, FT finger thoracostomy, ROSC return of spontaneous circulation, tCA traumatic cardiac arrest, ED emergency department

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

Clinical Bottom Line

Tension pneumothorax is a cause of traumatic cardiac arrest that must be considered and rapidly treated if suspected. Finger thoracostomy can be performed quickly and with a low rate of complications. It appears acceptable for use as a method of chest decompression in the pre-hospital environment. Further research is required to evaluate its use by non-HEMS crews, with consideration to integrating ultrasound detection into the clinical decision making where feasible.

Level of Evidence

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

References

1. Mistry, N.; Bleetman, A. & Roberts, K.J. Chest Decompression During the Resuscitation of Patients in Prehospital Traumatic Cardiac Arrest. Emerg Med J 2009; 26,738-740.
2. Peters J , Ketelaars R , van Wageningen B , et al. Prehospital Thoracostomy in Patients with Traumatic Circulatory Arrest: Results from a Physician-Staffed Helicopter Emergency Medical Service. Eur J Emerg Med 2017;24:96–100.
3. High, K.; Brywczynski, J. & Guillamondegui, O. Safety and Efficacy of Thoracostomy in the Air Medical Environment. Air Med J 2016; 35,227-230.