Prehospital Needle Decompression Should Not Be Compared With Trauma Center Chest Tube Placement

Abstract

To the Editor We read with great interest the recent article by Muchnok et al 1 reporting that prehospital needle decompression (PHND) was associated with lower 24-hour mortality compared with emergent trauma center chest tube placement in trauma patients. While we fully agree with the authors that PHND is a rare potentially lifesaving procedure, we believe that their results interpretation require some comments.We are surprised that the collected and analyzed prehospital and admission vital signs (systolic blood pressure, heart rate, respiratory rate, and Glasgow Coma Scale) do not include pulse oximetry and were used to assess PHND or tube thoracostomy efficacy. Respiratory rate is also affected by the underlying pH status, ie, acidemia induced by the shock status, irrespective of its origin. 2 As underlined by Muchnok et al, 1 prehospital diagnosis of patients needing PHND is not easy, all the more so if the pneumothorax is small and without immediate clinical repercussions, eg, respiratory distress, hypoxemia, and/or obstructive shock. The study by Muchnok et al 1 does not specify the indications of tube thoracostomy insertion, all pneumothorax independently of its size, or only pneumothorax with clinical impact, which may limit their results interpretation. Prehospital time duration in the study was relatively short, less than 45 minutes in both groups, reflecting the US prehospital emergency service organization. Thus, we can suppose that patients who benefited from PHND were only those with clinical consequences, as recommended. 3 For other patients with prehospital pneumothorax, we believe that its identification is a daily challenge for which prehospital pointof-care ultrasonography may help to improve identification. 4 Beyond pneumothorax identification, we believe that the real question is the indication of PHND or prehospital chest tube placement, both increasing prehospital time duration. Simi-larly, to the prehospital management of severe trauma, 5 prehospital time duration increase needed for PHND for pneumothorax should not be considered as a waste of time and represents the key point of the symptomatic posttrauma pneumothorax treatment.Beyond this, we agree with Muchnok et al 1 that earlier PHND for selected trauma patients is a lifesaving intervention that should be reinforced in emergency medical services education. A standardized approach to identify patients needing PHND since the prehospital setting would reduce variability in patient care and improve outcome.