Pre-hospital management of patients with severe thoracic injury

doi:10.1016/0020-1383(95)00107-K

Injury

Volume 26, Issue 9, November 1995, Pages 581-585

https://doi.org/10.1016/0020-1383(95)00107-K Get rights and content

Abstract

The physiological variables of oxygen saturation, blood pressure and pulse rate were compared in the pre-hospital phase and on arrival at hospital in a group of 63 patients with severe chest injury. Eighty-nine pre-hospital thoracic drainage procedures were carried out. Pre-hospital Advanced Trauma Life Support (ATLS) was associated with a significant improvement in all three variables. Median oxygen saturation increased by 17 per cent (P<0.001), median blood pressure increased from 90 to 120 mmHg (P<0.001) and median pulse rate decreased from 125 to 105 (P<0.001). Pre-hospital intervention is indicated for tension pneumothorax, and contraindicated for haemothorax without respiratory compromise. In other situations further evidence is required, and standard ATLS protocols should be used until this is available.

References (19)

KL Mattox et al.
Emergency thoroctomy for injury
Injury
(1986)
KL Mattox
Prehospital care of the patient with an injured chest
Surg Clin N Am
(1989)
A Hirshberg et al.
Pitfalls in the management of penetrating chest trauma
Am J Surg
(1989)
RC Daly et al.
The risk of percutaneous chest tube thoracostomy
Ann Emerg Med
(1985)
TJ Iberti et al.
Chest tube thoracostomy
Crit Care Clin
(1992)
American College of Surgeons
Subcommittee on advanced trauma life support
JE Campbell
Basic Trauma Life Support: advanced pre-hospital care
(1987)
DA Wilkinson et al.
ATLS on the ski slopes — a steamboat experience
J Trauma
(1992)
RJE Earlam et al.
Helicopter Emergency Medical Services — HEMS One
Ann Roy Coll Surg Eng
(1989)

There are more references available in the full text version of this article.

Cited by (39)

Emergency Medical Services Simple Thoracostomy for Traumatic Cardiac Arrest: Postimplementation Experience in a Ground-based Suburban/Rural Emergency Medical Services Agency
2018, Journal of Emergency Medicine
Citation Excerpt :
In a large series of trauma cases, chest injuries were thought to contribute to 20–25% of these traumatic deaths (2). Tension pneumothorax (TPT) is a well-described and common complication of blunt and penetrating chest injury, with a prevalence of 5–20% (3–6). Tube thoracostomy has long been the standard for treatment for TPT in the hospital setting yet is uncommon in prehospital care apart from helicopter EMS (HEMS).
Tube thoracostomy has long been the standard of care for treatment of tension pneumothorax in the hospital setting yet is uncommon in prehospital care apart from helicopter emergency medical services.
We aimed to evaluate the performance of simple thoracostomy (ST) for patients with traumatic cardiac arrest and suspected tension pneumothorax.
We conducted a retrospective case series of consecutive patients with traumatic cardiac arrest where simple thoracostomy was used during the resuscitation effort. Data were abstracted from our Zoll emergency medical record (Zoll Medical Corp., Chelmsford, MA) for patients who received the procedure between June 1, 2013 and July 1, 2017. We collected general descriptive characteristics, procedural success, presence of air or blood, and outcomes for each patient.
During the study period we performed ST on 57 patients. The mean age was 41 years old (range 15–81 years old) and 83% were male. Indications included 40 of 57 (70%) blunt trauma and 17 of 57 (30%) penetrating trauma. The presenting rhythm was pulseless electrical activity 65%, asystole 26%, ventricular tachycardia/fibrillation 4%, and nonrecorded 5%. Eighteen of 57 (32%) had air return, 14 of 57 (25%) return of spontaneous circulation, with 6 of 57 (11%) surviving to 24 h and 4 of 57 (7%) discharged from the hospital neurologically intact. Of the survivors, all were blunt trauma mechanism with initial rhythms of pulseless electrical activity. There were no reported medic injuries.
Our data show that properly trained paramedics in ground-based emergency medical services were able to safely and effectively perform ST in patients with traumatic cardiac arrest. We found a significant (32%) presence of pneumothorax in our sample, which supports previously reported high rates in this patient population.
Treatment of Thoracic Trauma: Lessons From the Battlefield Adapted to All Austere Environments
2017, Wilderness and Environmental Medicine
Severe thoracic trauma in the backcountry can be a formidable injury pattern to successfully treat. Traumatic open, pneumo-, and hemothoraces represent some of the most significant patterns for which advanced equipment and procedures may help leverage morbidity and mortality, particularly when evacuation is delayed and environmental conditions are extreme. This paper reviews the development of successful techniques for treating combat casualties with thoracic trauma, including the use of vented chest seals and the technique of needle thoracentesis. Recommendations are then given for applying this knowledge and skill set in the backcountry.
Chest trauma: First 48 hours management
2017, Anaesthesia Critical Care and Pain Medicine
Citation Excerpt :
Immediate pleural decompression is also mandatory in case of immediate life threatening conditions (i.e. hemodynamic instability and/or respiratory distress) associated with compressive pneumothorax, haemothorax or haemopneumothorax [59–61]. Apart from these specific situations, and in the absence of a confirmed diagnosis, close monitoring of the patient is required until appropriate imaging exams can be performed to confirm and characterise the pneumothorax (location, size, isolated or not) [62,63]. Recommendation 5.
Chest trauma remains an issue for health services for both severe and apparently mild trauma management. Severe chest trauma is associated with high mortality and is considered liable for 25% of mortality in multiple traumas. Moreover, mild trauma is also associated with significant morbidity especially in patients with preexisting conditions. Thus, whatever the severity, a fast-acting strategy must be organized. At this time, there are no guidelines available from scientific societies. These expert recommendations aim to establish guidelines for chest trauma management in both prehospital an in hospital settings, for the first 48 hours. The “Société française d’anesthésie réanimation” and the “Société française de médecine d’urgence” worked together on the 7 following questions: (1) criteria defining severity and for appropriate hospital referral; (2) diagnosis strategy in both pre- and in-hospital settings; (3) indications and guidelines for ventilatory support; (4) management of analgesia; (5) indications and guidelines for chest tube placement; (6) surgical and endovascular repair indications in blunt chest trauma; (7) definition, medical and surgical specificity of penetrating chest trauma. For each question, prespecified “crucial” (and sometimes also “important”) outcomes were identified by the panel of experts because it mattered for patients. We rated evidence across studies for these specific clinical outcomes. After a systematic Grade^® approach, we defined 60 recommendations. Each recommendation has been evaluated by all the experts according to the DELPHI method.
Physiology and cardiovascular effect of severe tension pneumothorax in a porcine model
2013, Journal of Surgical Research
Citation Excerpt :
The recognition and immediate intervention for signs of tension physiology in the trauma patient remains one of the most basic and important aspects of training medical personnel. This has been emphasized in all formal trauma training programs, including prehospital trauma life support and advanced trauma life support [18,19]. Similarly, the military has recognized the importance of treating tPTX on the battlefield, and it has been the focus of both didactic and skills training for all combat medics in the tactical combat casualty care course [20,21].
Pneumothoraces are relatively common among trauma patients and can rapidly progress to tension physiology and death if not identified and treated. We sought to develop a reliable and reproducible large animal model of tension pneumothorax and to examine the cardiovascular effects during progression from simple pneumothorax to tension pneumothorax.
Ten swine were intubated, sedated, and placed on mechanical ventilation. After a midline celiotomy, a 10-mm balloon-tipped laparoscopic trocar was placed through the diaphragm, and a 28F chest tube was placed in the standard position and clamped. Thoracic insufflation was performed in 5-mm increments, and continuous cardiovascular measurements were obtained.
Mean insufflation pressures of 10 mm Hg were associated with a 67% decrease in cardiac output (6.6 L/min versus 2.2 l/min; P = 0.04). An additional increase in the insufflation pressure (mean 15 mm Hg) was associated with an 82% decrease in cardiac output from baseline (6.8 versus 1.2 L/min; P < 0.01). Increasing insufflation pressures were associated with a corresponding increase in central venous pressure (from 7.6 mm Hg to 15.2 mm Hg; P < 0.01) and a simultaneous decrease in the pulmonary artery diastolic pressure (from 15 mm Hg to 12 mm Hg; P = 0.06), with the central venous pressure and pulmonary artery diastolic pressure approaching equalization immediately before the development of major hemodynamic decline. Pulseless electrical activity arrest was induced at an average of 20 mm Hg. Tension physiology was immediately reversible with adequate decompression, allowing for multiple repeated trials.
A reliable and highly reproducible model was created for severe tension pneumothorax in a large animal. Major cardiovascular instability proceeding to pulseless electrical activity arrest with stepwise insufflation was noted. This model could be highly useful for studying new diagnostic and treatment modalities for tension pneumothorax.
Initial Management and Resuscitation of Severe Chest Trauma
2012, Emergency Medicine Clinics of North America
Citation Excerpt :
Reviews of case series and reports of patients with TPTX show that tracheal deviation, oxygen desaturation, and hypotension are actually inconsistent findings in (awake) spontaneously ventilating patients (<25% each).30 By contrast, hypotension and low Sao2 are almost universally seen in PPV patients38,41; deviated trachea, a late finding, is found more frequently than in awake patients but not as consistently (60%).30,42,43 Many investigators state that clinicians should not seek radiologic confirmation if suspecting a TPTX: “the radiograph of a tension pneumothorax is one that should never be seen”.39,44,45
Emergency chest tube placement in trauma care-Which approach is preferable?
2007, Resuscitation
Citation Excerpt :
The criteria for a malposition are consistent with the literature.11,12,29,30 The frequency and diagnoses that indicated a chest tube are also confirmed by others.2,6,34 The overall rate of malpositioning was higher for the lateral approach, but not significantly different to the ventral approach.
Pneumothorax is present in about 20% of blunt major trauma cases. Insertion of an intercostal tube drainage is one effective treatment, however it is unclear whether the thoracostomy has more advantages if placed in the ventral (2.–3. intercostal space) or lateral (4.–6. intercostal space) approach. The aim of this study was to determine, whether there are any differences between the two approaches in respect of malposition and complications.
The data from 851 consecutive patients, admitted to our trauma centre from January 2000 to June 2004, was collected and analysed prospectively. The inclusion criteria were: ISS ≥ 16, insertion of an intercostal tube and subsequent thoracic computed tomography. Epidemiological and physiological data were analysed together with the location of the tube (ventral or lateral). The attending physician was free to choose the location of insertion. Chest tubes placed both on-scene and in-hospital chest tubes were investigated. Malpositions, defined as extrathoracic, abdominal, parenchymal or interlobal positions, were analysed by reviewing the computed tomography of the thorax (CT). Complications, like injuries to vessels or organs, infection or empyaema were analysed using our standardised prospective trauma protocol. Furthermore, the rate of clinically relevant malfunctions due to malposition was investigated as well as the number of chest tubes that had to be replaced.
One hundred and one chest tubes were inserted in 68 patients with multiple trauma (mean age 40.7, ISS = 38.1, AIS thorax = 3.9). In 21 cases a ventral approach was chosen (20.8%) and in 80 a lateral approach (79.2%). CT revealed malposition in two of the ventrally placed tubes (9.5%) and in 20 of the laterally placed tubes (25%) (p = 0.15, Fisher's exact test). One tube was identified in a subcutaneous location 17 chest tubes, after ventral approach all of them as a result of lateral approaches, were placed in the interlobe. No interlobal positions were observed in the ventral group. The interlobal position was found to be significantly higher in the lateral approach (p = 0.013, Fisher's exact test).
Clinically relevant malfunction was diagnosed in 6 of the 22 malpositioned chest tubes (5.9%). These tubes had to be repositioned, one was placed ventrally, the other five were placed laterally.
In our setting physicians preferred the lateral approach on-scene as well as in-hospital. In every fifth patient malpositioning of the tube was observed, mostly interlobal after lateral chest tube, however only few were associated with relevant clinical malfunctions. The probability of interlobal malpositioning is significantly higher when using the lateral approach as opposed to the ventral approach. Correction of malpositioned and ineffective chest tubes was necessary in every 17th case. No statistically significant difference between the two approaches for functional malposition was observed. Hence both approaches for emergency chest tube insertion seem to be equally justified.

View all citing articles on Scopus

View full text

PaperPre-hospital management of patients with severe thoracic injury

Abstract

Injury

Surg Clin N Am

Am J Surg

Ann Emerg Med

Crit Care Clin

Subcommittee on advanced trauma life support

Basic Trauma Life Support: advanced pre-hospital care

ATLS on the ski slopes — a steamboat experience

J Trauma

Helicopter Emergency Medical Services — HEMS One

Ann Roy Coll Surg Eng

Paper
Pre-hospital management of patients with severe thoracic injury