Page 51 - JSOM Spring 2021

Prehospital Needle Decompression Improves Clinical Outcomes in
Helicopter Evacuation Patients With Multisystem Trauma

A Multicenter Study

Reynold Henry, MD, MPH *; Cameron Ghafil, MD ; Adam Golden, MD, MPH ;
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Kazuhide Matsushima, MD ; Marc Eckstein, MD ; Christopher P. Foran, MD ;
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Hailey Theeuwen, MD ; David E. Bentley, MD ; Kenji Inaba, MD ; Aaron Strumwasser, MD, MSc 10
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ABSTRACT
Background: The utility of prehospital thoracic needle decom- pneumothorax. In the military setting, up to 33% of all pre-
pression (ND) for tension physiology in the civilian setting ventable deaths on the battlefield are estimated to result from
continues to be debated. We attempted to provide objective tension physiology. Tension pneumothorax has also been
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evidence for clinical improvement when ND is performed and cited as the second leading cause of preventable death in com-
determine whether technical success is associated with pro- bat casualties and the third leading cause of combat mortality
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vider factors. We also attempted to determine whether certain overall. Data from the Vietnam conflict demonstrated that up
clinical scenarios are more predictive than others of successful to 3.4% of patients with penetrating torso trauma who died
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improvement in symptoms when ND is performed. Methods: in the field potentially succumbed to tension pneumothorax.
Prehospital ND data acquired from one air ambulance service Increasing use of prehospital ND has led to a substantial de-
serving 79 trauma centers consisted of 143 patients (n = 143; crease in combat casualties from tension pneumothorax. Data
ND attempts = 172). Demographic and clinical outcome data from armed conflicts in Iraq and Afghanistan demonstrate a
were retrospectively reviewed. Patients were stratified by pre- mortality rate of only 0.2%, a reduction of nearly 90% from
hospital characteristics and indications. Objective outcomes the Vietnam conflict. Accordingly, current military prehospi-
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were measured as improvement in vital signs, subjective pa- tal guidelines support the broad use of ND in patients with
tient assessment, and physical examination findings. Univariate impending tension physiology or traumatic cardiac arrest, and
analysis was performed using chi-square for variable propor- this is the official recommendation of the US Department of
tions and unpaired Student’s t-test for variable means; p < .05 Defense Joint Trauma System, as stated in the Tactical Com-
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was considered statistically significant. Results: The success bat Casualty Care (TCCC) guidelines. The recommendations
rate of ND performed for hypoxia (70.5%) was notably higher allow for expedient management of patients with high-risk
than ND performed for hemodynamic instability (20.3%; mechanisms and respiratory symptoms, and the skill is in-
p < .01) or cardiac arrest (0%; p < .01). Compared to vital sign creasingly being taught to all military prehospital practitioners
parameters, clinical examination findings as part of the indica- as well as nonmedically trained combatants, given its proce-
tion for ND did not reliably predict technical success (p > .52 dural ease and perceived high clinical benefit. 9
for all indications). No difference was observed comparing reg-
istered nurse versus paramedic (p = .23), diameter of catheter In the civilian sector, ND is a standard aspect of the Advanced
(p > .13 for all), or length of catheter (p = .12). Conclusion: Pre- Trauma Life Support (ATLS) approach to the injured patient,
hospital ND should be considered in the appropriate clinical yet very little data supporting its use exist. 10,11 Similarly, pre-
setting. Outcomes are less reliable in cases of cardiopulmonary hospital providers are offered courses that provide in-depth
arrest or hypotension with respiratory symptoms; however, training regarding prehospital ND placement, such as Inter-
this should not deter prehospital providers from attempting national Trauma Life Support and Pre-Hospital Trauma Life
ND when clinically indicated. Additionally, the success rate of Support, although these courses are not a requirement for
prehospital ND does not appear to be related to catheter type most emergency medical services (EMS) agencies, and their
or the role of the performing provider. efficacy regarding prehospital ND has not been rigorously
examined. 12,13 As such, the clinical indications, optimal tech-
Keywords: needle decompression; prehospital emergency nique, and expected outcomes remain unclear. Although the
care; tension physiology; cardiopulmonary arrest technique is taught to medical students and residents as an
in-hospital resuscitative technique for tension physiology, a
notable proportion of these NDs are performed in the pre-
hospital setting by EMS providers, possibly because of acces-
Introduction
sibility to and/or provider preference for tube thoracostomy in
Prehospital thoracic ND is an emergent and potentially the inpatient setting. However, some evidence suggests that
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life- saving procedure designed to allow release of tension outcomes may be similar between the two techniques. 15
*Correspondence to reynold.henry@med.usc.edu
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1 Dr Henry, Dr Ghafil, Dr Golden, Dr Matsushima, Dr Foran, Dr Theeuwen, Dr Inaba are affiliated with the Division of Acute Care Surgery,
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LAC+USC Medical Center, Los Angeles, CA. Dr Eckstein is affiliated with the Department of Emergency Medicine, LAC+USC Medical Center,
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Los Angeles, Dr Bentley is affiliated with Air-Evac Lifeteam, O’Fallon, MO, and Dr Strumwasser are affiliated with the Division of Acute Care
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Surgery, LAC+USC Medical Center, Los Angeles, CA.
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