Page 80 - JSOM Summer 2024

Needle Decompression Complicated by Cardiac Injury
in a Prehospital Environment

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Kyle A. Davis¹*; Jeffrey J. Oury, MD ; Benjamin L. Reed, MD ;
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Daniel Grabo, MD ; Alison Wilson, MD ; Conley Coleman, DO 6
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ABSTRACT
Needle decompression is a mainstay intervention for tension provider, in the absence of a physician, it was determined that
pneumothorax in trauma medicine. It is used in combat and the patient met the indications for needle decompression due
prehospital medicine when definitive measures are often not to presumed tension pneumothorax. It is unclear whether the
available or ideal. It can temporarily relieve increased intra- location of the stab wounds or signs and symptoms prompted
thoracic pressure and treat a collapsed lung or great vessel the mid-level provider to perform the intervention. If a thor-
obstruction. However, when done incorrectly, it can result in ough assessment had been performed, it would have revealed
underlying visceral organ and vessel trauma. This is a case of no indication for needle decompression. The patient, however,
an adult male who presented to the emergency department subsequently underwent 14-gauge angiocatheter placement
after sustaining multiple stab wounds during an altercation. at the 4th intercostal space (ICS), left of the parasternal line.
On arrival, the patient had a 14-gauge angiocatheter inserted During transport, the patient received 4mg of ondansetron
at the 4th intercostal space (ICS), left of the parasternal line and 100μg of fentanyl intravenously. On-site medical profes-
traversing the right ventricle and interventricular septum and sionals clamped the angiocatheter owing to pulsatile blood re-
terminating in the left ventricle. The case emphasizes the im- turn through the catheter.
portance of understanding the landmarks of performing nee-
dle decompression in increasing the procedure’s efficacy and Upon arrival at an American College of Surgeons–verified
reducing iatrogenic complications. level 1 trauma center, the patient was alert and oriented. The
patient denied shortness of breath and chest pain. Initial vital
Keywords: needle decompression; cardiac injury; trauma; signs were a temperature of 36.8°C (98.2°F), heart rate of 75
tension pneumothorax; iatrogenic complications beats per minute, respiratory rate of 20 breaths per minute,
oxygen saturation of 100% on pulse oximetry, blood pres-
sure of 124/86mmHg, and mean arterial pressure (MAP) of
Introduction 98mmHg. Results for laboratory tests completed in the ED
showed significantly elevated troponin I at 1,771 nanograms/
Tension pneumothorax is a devastating disease process that liter (reference range: 0–30ng/L), a pH of 7.28 (reference
may be encountered in a prehospital environment, emergency range: 7.35–7.45) in arterial blood gas, and a lactate level of
department (ED), and on the battlefield. It is frequently due to 4.0mmol/L (reference range: 0.0–1.3mmol/L). The patient had
penetrating or blunt trauma to the thoracic cavity, resulting a history of seizure disorder and was currently prescribed di-
in an entrapment of air in the pleural space. Needle decom- valproex 500mg and levetiracetam 500mg.
pression can be performed rapidly in most environments as a
life-saving intervention. Although it is relatively simple in na- Physical examination revealed bilateral breath sounds and
ture, it is not a benign procedure. During the procedure, injury normal work of breathing on 2 liters of oxygen delivered via

to intrathoracic structures can occur when a patient’s anatomy nasal cannula. Chest examination was notable for a single
is not accounted for. stab wound to the left lateral flank at the level of the trans-
pyloric plane and a 14-gauge angiocatheter placed in the left
We present a patient with multiple stab wounds to the chest anterior chest. The right chest was atraumatic. Further eval-
and suspected tension pneumothorax who underwent needle uation revealed a stab wound to the left lateral back and a
decompression in a prehospital environment. The procedure stab wound to the left anterior thigh. The remaining physical
was complicated by the placement of the needle through the exam results were unremarkable. The patient was given 1g of
right ventricle and interventricular septum into the left ventri- cefazolin for bacterial prophylaxis and ketamine and fentanyl
cle with pulsatile bleeding from the catheter. for procedural analgesia.

Case Presentation Given the previously placed needle thoracostomy, the patient
underwent urgent left 28 French tube thoracostomy in the ED
An adult male presented to the ED via emergency aeromed- trauma bay. Ketamine was used for procedural analgesia and
ical transport after sustaining multiple stab wounds during the tube was connected to –20cmH 0 of suction. A chest radio-
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an altercation. During the primary assessment by a mid-level graph confirmed the placement of the chest tube, trace left-sided
*Correspondence to kad00013@mix.wvu.edu
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1 Kyle A. Davis, Dr. Jeffrey J. Oury, Dr. Daniel Grabo, Dr. Alison Wilson, and Dr. Conley Coleman are affiliated with the Department of Sur-
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gery, West Virginia University School of Medicine, Morgantown, WV. Dr. Benjamin L. Reed is affiliated with the Department of Surgery, Prisma
Health, Greenville, SC.
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