Safety and Efficacy of Thoracostomy in the Air Medical Environment

High, Kevin; Brywczynski, Jeremy; Guillamondegui, Oscar D.

doi:10.1016/j.amj.2016.04.002

Cited by 17 publications

(8 citation statements)

References 7 publications

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“…In the pre-hospital phase, this should not delay scene or transport times, but rather be performed, where possible, en route to hospital. Improvements to current care processes were not specifically assessed in this study including early trauma resuscitation techniques such as open thoracostomies instead of needle decompression, in conjunction with training and audit [45], routine pelvic splints and tourniquets in the presence of shock and the use of haemostatic gauze [46–48]. Consistent evidence highlighting harm from crystalloid resuscitation should translate into alternate fluid therapy in the setting of haemorrhagic shock.…”

Section: Discussionmentioning

confidence: 99%

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

et al. 2019

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Background Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients. Methods A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed. Results Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0). Conclusions Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.

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Section: Discussionmentioning

confidence: 99%

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

et al. 2019

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“…Chest tube placement has been previously validated for use in the prehospital environment by both physician and aeromedical nonphysician personnel. 4,8,9 This study is the first to the authors' knowledge to perform a matched direct comparison between nonphysician PTT and physician placed HTT, further validating the safety of this technique.…”

Section: Discussionmentioning

confidence: 67%

“…8 Similarly, High et al reviewed 421 tube and finger thoracostomies performed on 250 patients over a 90-month period by aeromedical personnel with a 3.4% rate of complications such as tube dislodgement or empyema. 9 Few studies, however, have compared the outcomes of trained aeromedical personnel PTT with physician placed hospital tube thoracostomy (HTT). York et al in 1993 compared 72 patients who underwent PTT with 100 patients treated by the in-hospital trauma service.…”

Section: Introductionmentioning

confidence: 99%

A Comparison of Prehospital Nonphysician and Hospital Physician Placed Tube Thoracostomy

Harrell

Brooks

Palm

et al. 2020

The American Surgeon

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Background Prehospital chest decompression can be a lifesaving procedure in severe chest trauma. Studies investigating prehospital chest decompression are mostly European where physicians are assigned to prehospital care units. This report is one of the first to compare demographics and outcomes in patients undergoing prehospital chest decompression by trained aeromedical nonphysician personnel to hospital chest decompression by physicians. Methods Prehospital tube thoracostomy (PTT) patients were identified from January 2014 to January 2019 and were matched in a 1:2 ratio based on age, Injury Severity Score (ISS), and chest Abbreviated Injury Score (AIS) to patients who underwent hospital tube thoracostomy (HTT) within 24 hours of admission. Results Forty-nine PTT patients were matched to 98 HTT patients. PTT patients had lower admission Glasgow Coma Scale (GCS), a higher rate of pre-chest tube needle decompression, and higher level 1 trauma activation. PTT were placed sooner (21.9 vs 157.0 minutes, P < .001). Rates of tube malposition, organ injury, tube dislodgement, empyema, and hospital-acquired pneumonia over the course of hospital admission were not significantly different between the 2 groups. PTT patients had longer intensive care unit length of stay (LOS), but similar hospital LOS, and overall mortality. Discussion This report demonstrates that PTT is performed sooner than hospital placed tubes. Complication rates associated with tube thoracostomy and patient outcomes were not statistically different between PTT and HTT groups.

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“…Im präklinischen Bereich stellt die klinische Untersuchung jedoch auch heute noch meist das einzige diagnostische Tool dar. Zunehmend kommt hier die Sonografie als apparative Diagnostik zum Einsatz [6,7,8]. Allein der dringende klinische Verdacht auf das Vorliegen eines Spannungspneumothorax oder eines massiven Hämatothorax bzw.…”

Section: Diagnostikunclassified

Thoraxdrainage beim Thoraxtrauma – Empfehlungen der interdisziplinären Arbeitsgemeinschaft Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und der Deutschen Gesellschaft für Unfallchirurgie (DGU)

et al. 2023

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ZusammenfassungDie Anlage einer Thoraxdrainage ist zwar grundsätzlich eine einfache, aber oft lebensrettende Notfallmaßnahme. Trotz der Häufigkeit der Prozedur zeigen sich jedoch Unsicherheiten im Umgang mit daraus resultierend hoher Komplikationsrate. Für alle Beteiligten stellt sowohl die Diagnostik, die Indikationsstellung und die Anlage selbst, wie auch das nachfolgende Management der Drainage eine wiederkehrende Herausforderung dar. Die Unter-AG Lungenverletzung der interdisziplinären AG (Arbeitsgemeinschaft) Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und Deutschen Gesellschaft für Unfallchirurgie (DGU) erarbeitete konsensuelle Behandlungsempfehlungen basierend auf einer Systematic-Review-like Literaturrecherche (MEDLINE via PubMed von 1997 bis 2022). Mit der aktuell vorliegenden Recherche konnten 60 repräsentative Arbeiten identifiziert werden, die Empfehlungen zulassen, jedoch meist nur einen niedrigen Evidenzgrad aufweisen. Die Empfehlungen sind nicht mit Evidenzgraden hinterlegt, sondern haben zunächst Konsenscharakter.Für den instabilen Patienten mit Thoraxtrauma stellt die Thoraxdrainage das Mittel der Wahl zur Entlastung eines Pneumothorax oder Hämatothorax dar. Beim Spannungspneumothorax sollte eine initiale Entlastungspunktion mit einer mindestens 5 cm langen Kanüle, gefolgt von der Anlage einer Thoraxdrainage erfolgen. Diagnostik und Beurteilung des Patienten sollten primär und im Verlauf durch die klinische Untersuchung, eine Röntgenuntersuchung des Thorax sowie eine Thoraxsonografie erfolgen, Goldstandard der Diagnostik ist jedoch die Computertomografie (CT). Beim kreislaufstabilen Patienten soll eine kleinlumige Drainage (z. B. 14 Charrière [Charr]) verwendet werden, instabile Patienten sollten eine großlumige Drainage erhalten. Thoraxdrainagen besitzen eine hohe Komplikationsrate zwischen 5% und 25%. Häufig sind insbesondere Fehlpositionierungen im Rahmen der Anlage. Eine Fehllage kann jedoch meist nur im CT sicher erkannt oder ausgeschlossen werden. Eine Therapie sollte mit mildem Sog erfolgen, ein Abklemmen vor Entfernung ist nicht zielführend. Der Drainagenzug kann sowohl am Ende der Inspiration oder Exspiration sicher erfolgen. Zur Verringerung der hohen Komplikationsrate sollte vermehrt der Fokus auf die Ausbildung und das Training der Anwender gelegt werden.

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Safety and Efficacy of Thoracostomy in the Air Medical Environment

Cited by 17 publications

References 7 publications

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

A Comparison of Prehospital Nonphysician and Hospital Physician Placed Tube Thoracostomy

Thoraxdrainage beim Thoraxtrauma – Empfehlungen der interdisziplinären Arbeitsgemeinschaft Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und der Deutschen Gesellschaft für Unfallchirurgie (DGU)

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