Frequency of Inadequate Needle Decompression in the Prehospital Setting
While browsing through PubMed yesterday, the following study caught my eye:
J Ultrasound Med. 2010 Sep;29(9):1285-9.
Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Department of Emergency Medicine, Northside Hospital Forsyth, 1200 Northside Forsyth Dr, Cumming, GA 30041 USA. email@example.com.
OBJECTIVE: 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.
METHODS: 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.
RESULTS: 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.
CONCLUSIONS: 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.
So what are the thoughts on this? I think that enrolling 57 patients in three years definitely qualifies this as a small study, and therefore presents the previously described problems with small studies. While completely ignoring the one patient who had three (!) decompression attempts performed, we’re left with an over-triage on 26% of the patients by EMS crews. The abstract doesn’t lay out how many patients presented to the trauma center with a confirmed pneumothorax who were not treated in the field, which is likely an important statistic to consider.
So if we subscribe to the goal of “first do no harm” and those 15 patients didn’t have a pneumothorax induced by the procedure, is their discomfort worth proper treatment for the remaining 42 patients? This study is obviously looking more at confirming a pneumothorax before placing a chest tube when a needle decompression has been performed, but it also raises some interesting questions for the EMS world. While a 0% over-triage is obviously ideal, it’s unlikely. So what is an acceptable number? What findings do you think are misinterpreted by prehospital personnel leading to an erroneous chest decompression? In my mind, providers are likely not decompressing based on a true tension pneumothorax and are performing the procedure on chest trauma patients with what they perceive are decreased lung sounds only without corresponding changes in vital signs. Just my two cents.
At any rate, needle decompression falls under the category of infrequent but important skills that we have in our collective scope. As that is the case, it is vital to use the procedure properly. Is this a training issue? An issue with initial education? A study method issue? Or something else?
The floor is yours, what say you?