Four years of pre-hospital simple thoracostomy performed by a physician-paramedic helicopter emergency medical service team: A description and review of practice

Abstract

Background: Essex and Herts Air Ambulance Trust operate doctor-paramedic pre-hospital care teams. Simple thoracostomy is performed if an intubated patient requires pleural decompression. Reports of the use of this technique are uncommon in the literature. This study describes the use of pre-hospital thoracostomy over four years. Pre-hospital complications and effect on oxygen saturations were also noted. Methods: A retrospective database review of all missions that occurred between 1 April 2010 and 31 March 2014. All patients undergoing this procedure were included. Results: A total of 126 patients were identified. In 110 (87%) of the total number of patients, the procedure was bilateral making the total number of thoracostomies performed 236. The mechanism of injury was blunt trauma in 115 (91%) and penetrating trauma in 11 patients (9%). The primary indication was traumatic cardiac arrest or peri-arrest in 51 patients (40%), high risk of pneumothorax in a ventilated patient in 45 patients (36%), pneumothorax diagnosed prior to delivery of anaesthesia in 17 patients (13%), and unexplained hypoxia in a ventilated patient in 13 patients (10%). The mean pulse oximetry measurement at the time of arrival was 91.8% and 97.2% at the time of handover (p¼0.003). No immediate complications were recorded on the database. Conclusion: We have described the regular use of the technique of simple thoracostomy in trauma patients attended by our air ambulance service. It is the largest case series to date of simple thoracostomy being used in the context of prehospital chest trauma.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

“…On the other hand, training of paramedics in these core competences of emergency medicine has improved during the last years, and success rates of prehospital airway management are primarily dependent on manual skills and extensive practical training of the prehospital clinicians rather than their profession as a paramedic or a physician. For example, a recent large case series found that well-trained paramedics were equally effective in performing thoracostomies in the prehospital setting as physicians (56). Other studies have shown that well-trained paramedics are able to perform safe and effective analgesia and triage as well as to apply clinical judgement in trauma patients (57,58).…”

Prehospital Decompression of Pneumothorax: A Systematic Review of Recent Evidence

“…A total of 1,420 unique citations were obtained by the literature search strategy, of which 20 original studies (two prospective cohort or case series and 18 retrospective cohort or cases series) fulfilled the inclusion criteria. [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] Each study included between 24 and 2,574 patients and most studies (n = 9) were conducted in the United States of America. The main mechanism was blunt trauma.…”

“…The main mechanism was blunt trauma. Twelve studies presented data on efficacy, patient outcomes, and/or adverse events, [19][20][21][22][23][24][25][26][27][28][29]36 while ten studies presented findings limited to anatomical measures and predicted success rate and outcomes (two studies presented results relevant to both categories). 19,[30][31][32][33][34][35][36][37][38] Characteristics of the included studies are presented in Table 1 and Table 2. Robitaille-Fortin, Norman, Archer, et al…”

“…The most clinically studied chest decompression technique was NCD (n = 7), [19][20][21]23,26,28,29 followed by FT (n = 5) [22][23][24][25]27 and CTP (n = 3). 21,25,26 Overall, the success rate of NCD ranged between 18% and 86%.…”

“…19,28 Using FT, the decompression success rate ranged between 9.7% to 32.0%. [22][23][24][25]27 In a case series of 250 patients following FT or CTP, the reported improvement rate was 30%. 25 One study found an improved oxygen saturation at hospital arrival compared to the on-field oxygen saturation prior to FT (P = .003).…”