The purpose of this study was to evaluate the frequency of inadequate needle chest thoracostomy in the prehospital setting in trauma patients suspected of having a pneumothorax (PTX) on the basis of physical examination.
This study took place at a level I trauma center. All trauma patients arriving via emergency medical services with a suspected PTX and a needle thoracostomy were evaluated for a PTX with bedside ultrasound. Patients too unstable for ultrasound evaluation before tube thoracostomy were excluded, and convenience sampling was used. All patients were scanned while supine. Examinations began at the midclavicular line and included the second through fifth ribs. If no sliding lung sign (SLS) was noted, a PTX was suspected, and the lung point was sought for definitive confirmation. When an SLS was noted throughout and a PTX was ruled out on ultrasound imaging, the thoracostomy catheter was removed. Descriptive statistics were calculated.
A total of 57 patients were evaluated over a 3-year period. All had at least 1 needle thoracostomy attempted; 1 patient underwent 3 attempts. Fifteen patients (26%) had a normal SLS on ultrasound examination and no PTX after the thoracostomy catheter was removed. None of the 15 patients were later discovered to have a PTX on subsequent computed tomography.
In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.
Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study
J Ultrasound Med. 2010 Sep;29(9):1285-9
Tag Archives: procedures
UK children sedation guideline
Despite the huge number of articles in the literature on paediatric sedation, one still encounters acrimonious debates about the appropriateness of non-anaesthetists doing it. How refreshing then, to see that the UK’s National Institute for Health & Clinical Excellence (“NICE”) has tackled this subject and come up with some reasonable recommendations. I’ve as yet only read the summary, but some of the good things are:
- No unachievable ‘two doctors present’ rule: ‘Two trained healthcare professionals should be available during sedation‘
- Differentiating painless imaging from painful procedures
- Monitoring standards that are appropriate for the age of child and depth of sedation (no mandatory blood pressure or ECG monitoring unless deep sedation; end-tidal capnography in deep sedation).
- Acknowledgement of the special features of ketamine: ‘Ketamine is a dissociative agent: the state of dissociative sedation cannot be readily categorised as either moderate or deep sedation; the drug is considered to have a wide margin of safety.’
- Recognition that specialists other than anaesthetists may have specialist sedation and airway skills
There are some rather conservative recommendations on fasting, although the wording of the guideline in my interpretation allows some flexibility if ketamine is used for an emergency procedure.
Sedation in children and young people
National Institute for Health & Clinical Excellence
Paediatric airway gems
Dr Rich Levitan has made an enormous contribution to the science and practice of emergency airway management, as his bibliography demonstrates. In a new article in Emergency Physicians Monthly entitled ‘Demystifying Pediatric Laryngoscopy’, Rich covers some great tips for optimising laryngoscopic view in kids.
Check this excerpt out for an example:
“During laryngoscopy in infants the epiglottis and uvula are often touching; the epiglottis may be located within an inch of the mouth. Often the epiglottis lies against the posterior pharynx, and it is critical to have a Yankauer to dab the posterior pharynx as the laryngoscope is advanced. Hyperextension of the head pushes the base of tongue and epiglottis backwards against the posterior pharyngeal wall, and makes epiglottis identification more difficult”
Gems like this come thick and fast when you hear or read what Rich has to say. Seven years ago I was left reeling after finishing his ‘Airway Cam Guide to Intubation and Practical Emergency Airway Management‘ which profoundly influenced the way I practice and teach emergency airway skills, including on the Critical Care for Emergency Physicians course.
I’ve finally gotten round to booking a place on one of his courses in March in Baltimore. I’ll let you know how it goes. In the mean time, I’d like to point you toward his training videos as a great educational resource, like this one that demonstrates for novice laryngoscopists the difference between the appearances of trachea and oesophagus, the former having recognisable, defined posterior cartilagenous structures:
Demystifying Pediatric Laryngoscopy
Emergency Physicians Monthly January 19, 2011
A French FIRST in pre-hospital medicine
A contribution has been made to the literature supporting physician intervention in some pre-hospital trauma patients, in the form of the FIRST study: French Intensive care Recorded in Severe Trauma. 
Not exactly the class 1 evidence we’d (well, I’d) like to see, but a prospective study from France comparing outcomes in patients treated by routine pre-hospital providers with those managed in the field by emergency physicians working for SMUR (Service Mobile d’Urgences et de Réanimation). Primary outcome was 30-day mortality. Only patients admitted to an ICU were included, and researchers were not blinded to which group (SMUR vs nonSMUR) patients belonged. A large group of SMUR patients (2513) was compared with a much smaller (190) nonSMUR group.
Patients were sicker in the SMUR group (lower GCS and SpO2, higher Injury Severity Score, higher frequency of abnormal pupils). Unadjusted mortality was not significantly different but when adjustment for ISS and physiological status was made (I don’t really understand how this was done), SMUR care was significantly associated with a reduced risk of 30-day mortality (OR: 0.55, 95% CI: 0.32-0.94, p = 0.03).
Lots of interesting points in this study, most of which ask more questions that they answer. The French pre-hospital physicians have an aggressive approach to trauma resuscitation, doing rapid sequence intubation in more than a half of their patients and even starting catecholamine infusions as a fluid-sparing strategy in shocked patients. The full text link is worth a read for those interested in this area of medicine.
Medical pre-hospital management reduces mortality in severe blunt trauma: a prospective epidemiological study
Critical Care 2011, 15:R34
Full text as provisional PDF
Open thoracostomy
Not a new paper to cite here, just a collection of resources that refer to open thoracostomy in trauma.
A longstanding practice by some European and Australasian HEMS physicians, open thoracostomy is essentially a chest tube procedure without the actual intercostal catheter: the surgical incision is made, blunt dissection is performed, and the pleura penetrated. The wound is then left open.
This is a rapid way of decompressing a tension pneumothorax in a critically injured trauma patient who is intubated. The positive pressure ventilation prevents the thoracostomy wound from acting as an open, ‘sucking’, chest wound.
In many pre-hospital services this is the preferred approach to pleural decompression in an intubated patient, and also forms part of the approach to resuscitation in traumatic cardiac arrest.
Some principles to consider are:
- A tube and drainage system are not necessary for the drainage of air, but should be used if there is signficant haemothorax
- The tissues may re-appose during transport so physiological deterioration should prompt a re-fingering of the thoracostomy to re-establish the drainage tract and allow air to escape
- Standard intravenous cannula devices may be shorter than the distance from chest wall to pleural space in many adults, adding to the inadequacy of needle decompression
- Signs of tension pneumothorax are rarely if ever as obvious as the textbooks suggest – unexplained shock or hypoxaemia in a patient with actual or probably thoracic trauma should prompt consideration of pleural decompression even in the absence of obvious clinical signs of pneumothorax – subtle evidence only may exist, such as palpable subcutaneous emphysema
- This should only be done in intubated patients undergoing positive pressure ventilation!
This video shows the procedure, done by a relative beginner; a slightly larger incision with more assertive dissection would make it faster and more effective
Not yet heard Scott Weingart’s excellent podcast on traumatic arrest, which includes open, or ‘finger’, thoracostomy? You can find it here
Thoracostomy references
Simple Thoracostomy Avoids Chest Drain Insertion in Prehospital Trauma
J Trauma 1996 39(2):373-374
Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews
European Journal of Emergency Medicine 2006, 13:276–280
Prehospital thoracostomy
European Journal of Emergency Medicine 2008, 15:283–285
Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest
Emerg. Med. J. 2009;26;738-740
Life-saving or life-threatening? Prehospital thoracostomy for thoracic trauma
Emerg Med J 2007;24:305–306
Pre-Hospital and In-Hospital Thoracostomy: Indications and Complications
Ann R Coll Surg Engl. 2008 January; 90(1): 54–57
Needle decompression is inadequate:
Needle Thoracostomy in the Treatment of a Tension Pneumothorax in Trauma Patients: What Size Needle?
J Trauma. 2008;64:111–114
Pre-hospital management of patients with severe thoracic injury
Injury 1995 26(9):581-5
Pre-hospital iv and increased mortality
The US media seem to be making a big thing of a recent article published ahead of print which demonstrates an association between increased mortality from trauma and the insertion of an intravenous line with or without the administration of fluid.
This was a retrospective cohort study of over 770 000 patients from the National Trauma Data Bank. Approximately half (49.3%) received ‘prehospital IV’, which could mean fluids, or could just mean insertion of an intravenous cannula: ‘we could not definitively differentiate IV fluid administration versus IV catheter placement alone‘.
Unadjusted mortality was significantly higher in patients in the prehospital IV group, although the abstract inaccurately reports this to be ‘in patients receiving prehospital IV fluids‘ (4.8% vs. 4.5%, P < 0.001).
Multivariable logistic regression was used to examine the relationship between prehospital IV and mortality in the 311,071 patients with complete data. After adjustment, prehospital IV patients had significantly higher mortality than those without a prehospital IV. The odds ratio of death associated with prehospital IV placement was 1.11 (95% CI 1.06–1.17). When Dead-On-Arival patients were excluded from the group as a whole, the association persisted (OR 1.17, 95% CI 1.11–1.23).
On subgroup analyses, the association between IV placement and excess mortality was maintained in nearly all patient subsets; the effect was more exaggerated in penetrating trauma victims.
Media speculation as to the reason for this association abounds, like USA Today‘s ‘those who are given pre-hospital IV fluids are actually 11% more likely to die than those who aren’t, not only because of transport delays but also in part because of the increased risk for bleeding that can accompany a fluid-induced increase in blood pressure‘. However the study did not record any pre-hospital times and could not tell which patients received fluid, let alone what the effect of fluid on blood pressure was.
The authors are open about this and other limitations: ‘The NTDB did not report prehospital transport times or differentiate urban versus rural care. Thus, we could not examine whether excess mortality in patients treated with IVs was directly associated with delays in transport to definitive care. We were also not able to control for transport time within the multiple regression model or perform a stratified analysis by urban versus rural patients. Perhaps this analysis would have identified a subset of patients who may benefit from IV placement‘.
No doubt this will be added to the pile of mainly hypothesis-generating literature quoted by the scoop-and-run brigade whose black-and-white worldview includes paramedics who want to delay proper treatment and a homogeneous trauma population whose lives can only be saved by a trauma surgeon in a hospital. Those who have evolved colour vision find this an interesting, but hardly practice-changing study; caution regarding injudicious fluid administration has been the game plan for many civilian and military pre-hospital providers since early last decade, and it is clear that different patients with different injury patterns, different degrees of physiological derangement, and different distances from the right hospital will continue to have different clinical needs specific to their presentation, some of which are likely to be of benefit if provided in the field, through an intravenous line.
Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis
Ann Surg. 2010 Dec 20. [Epub ahead of print]
Bleeding Tracheostomy
Adapted from the UK Intensive Care Society’s ‘Standards for the care of adult patients with a temporary tracheostomy‘
Bleeding from an established tracheostomy (ie. ‘late bleeding’, as to opposed to peri-operative bleeding that is more common and often benign) may occur because of erosion of blood vessels in and around the stoma site. This is more likely if there has been infection of the stoma site. Such bleeding may settle with conservative management. More worryingly, however, is the prospect of such bleeding being the result of erosion of a major artery in the root of the neck where there has been pressure from the tracheostomy tube itself or the cuff tube. Most commonly, this erosion occurs into the right brachiocephalic artery (also known as the innominate artery), resulting in a tracheo-innominate artery fistula. This situation may be heralded in the preceding hours by a small, apparently insignificant, sentinel bleed. Bleeding from such a fistula will be massive. THIS IS A LIFE-THREATENING EMERGENCY and so decisions need to be rapidly made.
- Call for help– senior medical and nursing staff, other health professionals with tracheostomy care skills (e.g. respiratory therapist, physiotherapist).
- Clear airway – blood clots may need to be suctioned.
- Replace blood products as required
- Bleeding may be temporarily reduced or stopped by applying finger pressure to the root of the neck in the sternal notch, or by inflating the tracheostomy tube cuff (if present) with a 50ml syringe of air. This inflation should be done slowly and steadily to inflate the balloon to a maximum volume without bursting it. Depending on the type and size of the tracheostomy tube this may be anywhere between 10 and 35 ml.
- Urgent referral for surgical exploration must now be made, if not already done so. In addition to an ENT or maxillofacial surgeon, it may be necessary to get help from a vascular surgeon. Sometimes, the damage can only be repaired utilising cardio-pulmonary bypass, and so a cardiothoracic surgeon may also be needed to help.
- Consider palliation – it is well recognised that fatalities occur in this situation, and that this may be the mode of death for some patients with head and neck cancers
A tracheal tube in the chest
Intercostal catheters can kink, obstruct, or get pulled out. These hazards are greater during transport of the patient. Critical care and retrieval medicine doctors in Queensland, Australia (where many people are having a bad time right now) have invented an elegant alternative: using a cuffed tracheal tube in the pleural space instead. It can be attached to a Heimlich valve.
They even used a bit of science to demonstrate its effectiveness, by creating pneumothoraces and haemothoraces in sheep and comparing the tracheal tube with a standard intercostal catheter (ICC).
The method for insertion is simple:
- Breach the pleura
- Insert a 14 Fr Cook intubating bougie into the thoracic cavity
- Railroad a 7.0 mm internal diameter tracheal tube (ETT) into the chest cavity
- Inflate the cuff
- Retract the tube until resistance is felt.
- Remove the ETT connector
- Attach a Heimlich valve
The results of the comparison are convincing: ‘The ETT proved faster to insert for both sheep. This was likely because it did not require suturing. Both the ETT and the ICC were comparable in draining blood. It was noted that neither tube was particularly effective when the haemothorax was positioned ‘side-up’. When turned ‘side-down’, both tubes successfully drained blood. Despite having multiple drainage ports, the ICC required more manipulation and was noted to kink. Conversely, the ETT with a single lumen and a Murphy eye, was stiffer and drained a similar amount of blood without the catheter having to be milked.’
Proposed advantages of this method include:
- More portable equipment
- Faster insertion
- Provides kit redundancy
- Does not require suturing
- Avoids operator trauma from any sharp edges such as a fractured rib. (No attempt was made to place a finger into the chest cavity in the ETT group).
- Allows for a smaller incision
- Less trauma to the insertion site
- Might also offer a back up, when conventional equipment has been exhausted.
The authors graciously note that both Portex and Cook have developed ICC kits that now go some way in supporting the original idea behind this study. These include flexible introducers (Portex) and guidewire insertion technique (Cook).
Appraisal of the endotracheal tube as an alternative to the intercostal catheter
Emerg Med Australas. 2010 Dec;22(6):573-4
Cuff pressures and tracheal injury
We all intubate patients with cuffed tubes, but we’re far too busy and important to fart around measuring tracheal tube cuff pressures when we’re saving lives right? Surely something the ICU nurses can sort out between ‘eye care’ and swabbing for MRSA.
The modern ‘high volume low pressure’ cuff has certainly led us to worry less about cuff pressures, and in frontline critical care specialties like emergency medicine and pre-hospital and retrieval medicine it’s the last thing on our minds. However we should consider the accumulating pool of evidence that tells us:
- Physicians are hopelessly poor at estimating cuff pressures based on palpating the pilot balloon
- Cuff pressures are frequently very high
- Tracheal mucosal injury can occur even after short term intubation (a few hours)
- When the pressure in the cuff exceeds 22 mm Hg, blood flow in the tracheal mucosa begins decreasing
- Tracheal mucosal blood flow reduces markedly when the pressure reaches 30 mm Hg
- When the pressure in the cuff reaches 50 mm Hg for 15 minutes, ischemic injury to the tracheal mucosa can occur
A study from China tested the hypothesis that an appropriate tracheal tube cuff (ETTc) pressure even in short procedures would reduce endotracheal intubation–related morbidity. They compared bronchoscopic appearance of tracheal mucosa, and patient symptoms of tracheal injury, in two groups of elective surgical patients anaesthetised and intubated between 120 and 180 minutes: a control group without measuring ETTc pressure, and a study group with ETTc pressure measured and adjusted to a range 15-25 mmHg. The endoscopist was blinded to the study group allocation.
_7093.jpg)
The mean ETTc pressure measured after estimation by palpation of the pilot balloon of the study group was 43 +/- 23.3 mm Hg before adjustment (the highest was 210 mm Hg), and 20+/- 3.1 mm Hg after adjustment (p< 0.001). The incidence of postprocedural sore throat, hoarseness, and blood-streaked expectoration in the control group was significantly higher than in the study group. As the duration of endotracheal intubation increased, the incidence of sore throat and blood-streaked expectoration in the control group increased. The incidence of sore throat in the study group also increased with increasing duration of endotracheal intubation. Fiberoptic bronchoscopy showed that the tracheal mucosa was injured in varying degrees in both groups, but the injury was more severe in the control group than in the study group.
So..time to get a cuff manometer for your ED or helicopter? Perhaps you already have one. What do you think?
Correlations Between Controlled Endotracheal Tube Cuff Pressure and Postprocedural Complications: A Multicenter Study
Anesth Analg. 2010 Nov;111(5):1133-7
Related posts:
Cuff pressure in flight
Paediatric cuff pressures
Less smelly than chicken drumsticks
Emergency and orthopaedic doctors Elizabeth and Anthony Bateman from Britain describe their method of making a bone simulator for intraosseous cannulation training:
- Take up to one Crunchie bar per trainee (leave in wrapper!) – this simulates the cancellous bone that is cannulated.
- Tightly plaster cast with four layers of polyester cast tape (12.5 cm width matches closely to Crunchie bar length), cutting lengths of the cast tape as needed prior to immersing in water – this simulates the hard cortical bone.
- Foam padding, or two layers of wool band from the plaster room, can be added to simulate soft tissue.
A quick google reveals it can be a challenge getting Crunchie bars in the United States. Maybe there’s a suitable honeycomb-centred alternative. If not you can resort to ordering them from Amazon.
Intraosseus access simulation: the Crunchie solution
Emerg Med J. 2010 Dec;27(12):961