Page 20 - JSOM Winter 2018

Larger-Caliber Alternative Devices for Decompression of
Tension Hemopneumothorax in the Setting of Hemorrhagic Shock

Christian S. McEvoy, MD, MPH *; Matthew L. Leatherman, DO ; Jenny M. Held, MD ;
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Laura M. Fluke, DO ; Robert L. Ricca, MD ; Travis M. Polk, MD 1,2
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ABSTRACT
Background: The 14-gauge (14G) angiocatheter (AC) has an on early recognition and rapid thoracic decompression. The
unacceptably high failure rate in treatment of tension pneumo- current standard for emergent treatment is needle thoracos-
thorax (tPTX). Little is known regarding the interplay among tomy (NT) with a 14G AC in the second intercostal space at
hemorrhage, hemothorax (HTX), and tPTX. We hypothesized the midclavicular line. 5,6,8
that increased hemorrhage predisposes tension physiology and
that needle decompression fails more often with increased Failure rates for 14G AC NT are unacceptably high, ranging
HTX. Methods: This is a planned secondary analysis of data from 17% to 60% in various animal, cadaver, radiographic,
from our recent comparison of 14G AC with 10-gauge (10G) and human series. 8–13 Failure may result from inadequate de-
AC, modified 14G Veress needle, and 3mm laparoscopic tro- compression, improper placement, kinking, or dislodgement,
car conducted in a positive pressure ventilation tension hemo- as well as contributory device characteristics including length,
pneumothorax model using anesthetized swine. Susceptibility rigidity, and caliber. 11,14–17 A need for an alternative device that
to tension physiology was extrapolated from volume of carbon mitigates these potential etiologies of decompression failure
dioxide (CO ) instilled and time required to induce 50% re- has been recognized. 9,10,14,15,18,19
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duction in cardiac output. Failures to rescue and recover were
compared between the 10% and 20% estimated blood volume Several solutions have been proposed, including use of an ax-
(EBV) HTX groups and across devices. Results: A total of 196 illary needle decompression site, use of longer catheters or
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tension hemopneumothorax events were evaluated. No differ- larger-caliber catheters, 9,18,19 and more-rigid devices that are
ences were noted in the volume of CO instilled nor time to less prone to kinking. 9,10,19 In fact, the longer 8cm (3.25 in)
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tension physiology. HTX with 10% EBV had fewer failures AC is now considered the standard of care, 12,21–26 and the fifth
compared with 20% HTX (7% versus 23%; p = .002). For intercostal space at the anterior axillary line is considered an
larger-caliber devices, there was no difference between HTX acceptable site for NT, because of thinner chest wall thick-
groups, whereas smaller-caliber devices had more failures and ness, improved provider accuracy and confidence, 20,23,25–27 and
longer time to rescue with increased HTX volume as well as a lower rate of dislodgement with patient movement. 15
increased variability in times to rescue in both HTX volume
groups. Conclusion: Increased HTX volume did not predis- Traumatic pneumothoraces are injuries that rarely occur in
pose tension physiology; however, smaller-caliber devices were isolation and associated hemothoraces are reported to occur
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associated with more failures and longer times to rescue in after thoracic trauma in as many as 80% of cases. Likewise,
20% HTX as compared with 10% HTX. Use of larger devices other sources of systemic hemorrhage in the patient with
for decompression has benefit and further study with more polytrauma are common. Little is known regarding the per-
profound hemorrhage and HTX and spontaneous breathing formance of the standard 14G AC or any of the proposed al-
models is warranted. ternative decompression devices for treatment of tPTX with a
concomitant HTX or systemic hemorrhage.
Keywords: tension pneumothorax; needle decompression;
needle thoracostomy; trauma; prehospital care; hemothorax Previously suggested alternatives to the 14G AC include a
modified 14G Veress-type needle (mVN), laparoscopic trocar
(LT), and 10G AC. Using a positive-pressure ventilation York-
Introduction shire swine model, our laboratory recently conducted a com-
prehensive, randomized comparison of multiple alternative
Tension pneumothorax (tPTX) is a potentially treatable cause decompression devices for tension hemopneumothorax (t-H/
of death across military and civilian spectrums of care, with a PTX) and tension-induced pulseless electrical activity (PEA).
reported incidence of 1% to 5%. Patient survival depends In this study, we found that the 14G mVN performed similarly
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*Correspondence to LT Christian S. McEvoy, MD, MPH, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA
23708; or christian.s.mcevoy.mil@mail.mil
1 LT McEvoy, MC, USN; LT Leatherman, MC, USN; LT Held, MC, USN; LT Fluke, MC, USN; CAPT Ricca, MC, USN; and CDR Polk, MC,
USN, all are at Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA. CDR Polk also is at Navy Trauma Training Center,
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Los Angeles County and University of Southern California Medical Center, Los Angeles, CA.
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