 arrest are based on cases when definitive management with tube thoracostomy and pericardiocentesis are performed in the ED. Because we don’t have many data points in close proximity in time to the point of injury, we must remain hopeful that moving definitive intervention to the field may generate more favorable outcomes.
To address this concern, the Montgomery County (Texas) Hospital District (MCHD) developed a strategy to manage traumatic cardiac arrest with associated chest trauma in the prehospital setting in 2010. The “three hole punch technique” involved the placement of bilateral needle thoracostmies and a blind pericardiocentesis in patients with chest trauma as a contributor to cardiac arrest. Although this technique proved relatively easy and useful, there were growing concerns regarding the needle thoracostomy technique.
When the needle is inserted to relieve a tension pneumothorax and no rush of air is heard, it’s impossible to deduct whether this is due to no tension pneumothorax being present, improper placement, kinking or plugging of the catheter, or if the tension pneumothorax is localized or loculated.12 A tension pneumothorax that was initially relieved may also re-accumulate undetected as a result of catheter kinking or plugging.
To avoid the complications associated with needle decompression, a number of services in Europe have adopted simple thoracostomy as an option for chest decompression. Simple thoracostomy is a technique similar to the placement of a chest tube, traditionally done in the ED. It utilizes an incision with a scalpel and penetration directly into the thoracic cavity with forceps and a gloved finger to relieve the tension pneumothorax. The only major difference is that the chest tube isn’t inserted.
In an age when EMS is now a physician medical subspecialty, medical directors are compelled to move out of the “cowboy days” and enter an era where they recognize and respect the standard of care. They must also realize when they’re advancing beyond that standard and engage the medical community in discussions about protocol development.
Those of us spearheading MCHD’s prehospital simple thoracostomy procedure recognized we had to get buy-in from stakeholders and potential critics. Prior to initiation, we discussed the concept, training program and clinical guidelines with our receiving trauma centers, EDs, trauma surgery services, and even other EMS services in the region. We also asked for feedback and if moving from needle to simple thoracostomy was a reasonable extension of the current standard of care.
A major concern of receiving hospitals was risks for both the patient and provider. However, there’s no risk to patients because this procedure is only used when all other care would be futile and resuscitation efforts are withheld or terminated. The only significant risk was of potential injury to the paramedic, either caused by using the scalpel or injuring the finger with fragmented bones or other debris upon insertion into the chest. Because of this, the procedure is optional for those at the appropriate clinical level and is an individually credentialed skill.
Consensus approval from the stakeholders, earned by creating an open dialogue in the community, allowed us to move forward with implementation.
The MCHD simple thoracostomy clinical guidelines were developed based upon London’s Air Ambulance protocol and provided research. Due to the novelty of this procedure by ground EMS units, we chose to utilize the technique solely in patients suffering from traumatic cardiac arrest with clear indications and contraindications. The procedure is not used in any other clinical scenario at this time.
Simple thoracostomy indications: Simple thoracostomy may only be performed on patients with traumatic cardiac arrest with known or suspected injury to the chest and/or abdomen.
Have loss of cardiac output for greater than 10 minutes.
Description of procedure: Place the patient supine with the arm on the affected side abducted and externally rotated with palm of the hand behind the patient’s head if possible. The paramedic must be positioned on the affected side, perpendicular to the patient. The site should be cleansed and, using a scalpel, a 1–2-inch incision is made between the fourth and fifth intercostal space at the midaxillary line over the rib. Usually this will be above the nipple line (males) and breast tissue should be lifted out of the way of the incision (females).
The scalpel is used for the skin only, followed by the use of blunt dissection with a large, curved clamp in a caudal direction. Following rapid blunt dissection, the curved clamp, in a controlled fashion, is used to pass through the intercostal muscles and penetrate into the pleural space. With the curved tips remaining just inside the pleural space, the clamp is opened widely to allow the expulsion of air and blood and subsequently pulled out. The ostomy through the intercostal muscles should allow free insertion of a finger without pushing and should be large enough to prevent re-tension from occurring.
A finger is inserted through the ostomy site and into the pleural space. Once in the pleural space, palpation of the parietal pleura and lung with the finger is necessary to ensure you’ve entered the thoracic cavity and that the possible tension pneumothorax causing the traumatic cardiac arrest has been managed. Confirmation of entry is also essential to ensure you haven’t entered subcutaneous fat. This technique also gives indisputable confirmation that you’re in the right place. This is an important difference to needle decompression, which doesn’t give indisputable confirmation of appropriate positioning nor an intact conduit to the space in the prehospital setting.
An occlusive dressing is then utilized to cover the wound. Each wound is circled with a permanent marker and labeled “EMS–L” (left) or “EMS–R” (right). This identifies incisions made by EMS in the event of autopsy or criminal investigation.
After development of the clinical guidelines, the department of clinical services (DCS) at MCHD developed a training program and deployment and outcome measurement strategies. The training takes place at Baylor College of Medicine’s Experimental Surgery and Surgical Training Laboratory. The educational component of the procedure, led by direct physician oversight, consists of three parts.
The first component is four hours of didactics covering the indications, contraindications, complications, equipment familiarization, positioning, technique and precautions of the procedure.
The second component is hands on, where MCHD paramedics perform a simple thoracostomy on an anesthetized swine model with direct physician supervision in a step-by-step fashion.
The third and final phase of training is scenario-based application of the procedure on the anesthetized swine.
Ongoing training is required twice a year in the anesthetized swine lab in order to maintain credentialing. It’s critical when introducing a high-risk, low-frequency, novel technique to ensure the service is financially committed to appropriate initial and continuing education as well as 100% quality review. Skill dilution is an important consideration, as well as both financial and practical considerations, which is why MCHD chose to train only supervisors and senior-level paramedics. Currently, 30 paramedics—approximately 10% of paramedics in the countywide system—have received this training.
One Sharpie permanent marker.
The final step in the development of the initiation of the simple thoracostomy procedure included tracking, documenting and reviewing clinical and operational quality review data elements. Currently the goal is 100% case review from initial EMS contact to final case disposition. To accomplish this, ZOLL ePCR interventions were created and are now tracked and reviewed by the MCHD trauma coordinator and medical director for appropriate indications, contraindications, complications and adverse events.
Follow-up on each case is managed by the DCS trauma coordinator, who collects information from the EMS record, hospital record, and autopsy report in cases of death to prepare the case file for review. All cases are reviewed by the EMS medical directors followed by a case review meeting performed with the EMS crew and supervisor. There have been no adverse events or paramedic injuries associated with this procedure to date.
Simple thoracostomy in our system has been developed as a safe method for extensively trained paramedics to resolve the potentially life-threatening condition of tension pneumothorax and associated traumatic cardiac arrest. Effective deployment of this procedure in an EMS service is dependent on stakeholder buy-in, appropriate training, frequent retraining, and 100% quality review. In the future, we’ll publish the result(s) from our research-developed protocol, training, deployment and quality review.
1. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS). Retrieved Nov. 10, 2013, from www.cdc.gov/injury/wisqars/.
2. Sanders MJ: Mosby’s paramedic textbook, edition 3. Elsevier Mosby: St. Louis, Mo., pp. 630–651, 2007.
4. Eckstein M, Suyehara D. Needle thoracostomy in the prehospital setting. Prehosp Emerg Care. 1998;2(2):132–135.
5. McSwain NE, Frame S, Paturas JL: Mosby PHTLS basic and advanced prehospital trauma life support, fourth edition. Mosby: St. Louis, Mo., pp. 110–135, 1999.
6. Campbell JE: International trauma life support for emergency care providers, seventh edition. Pearson: Saddle River, N.J., pp. 108–139, 2012.
7. Massarutti D, Trillo G, Berlot G, et al. Simple thoracostomy in prehospital trauma management is safe and effective: A 2-year experience by helicopter emergency medical crews. Eur J Emerg Med. 2006;13(5):276–280.
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