Prehospital Trauma Compendium: Traumatic Pneumothorax Care – a position statement and resource document of NAEMSP

Abstract

ABSTRACT Emergency Medical Services (EMS) clinicians manage patients with traumatic pneumothoraces. These may be simple pneumothoraces that are less clinically impactful, or tension pneumothoraces that disturb perfusion, lead to shock, and impart significant risk for morbidity and mortality. Needle thoracostomy is the most common EMS treatment of tension pneumothorax, but despite the potentially life-saving value of needle thoracostomy, reports indicate frequent misapplication of the procedure as well as low rates of successful decompression. This has led some to question the value of prehospital needle thoracostomy and has prompted consideration of alternative approaches to management (e.g., simple thoracostomy, tube thoracostomy). EMS clinicians must determine when pleural decompression is indicated and optimize the safety and effectiveness of the procedure. Further, there is also ambiguity regarding EMS management of open pneumothoraces. To provide evidence-based guidance on the management of traumatic pneumothoraces in the EMS setting, NAEMSP performed a structured literature review and developed the following recommendations supported by the evidence summarized in the accompanying resource document. NAEMSP recommends: EMS identification of a tension pneumothorax must be guided by a combination of risk factors and physical findings, which may be augmented by diagnostic technologies. EMS clinicians should recognize the differences in the clinical presentation of a tension pneumothorax in spontaneously breathing patients and in patients receiving positive pressure ventilation. EMS clinicians should not perform pleural decompression in patients with simple pneumothoraces but should perform pleural decompression in patients with tension pneumothorax, if within the clinician’s scope of practice. When within scope of practice, EMS clinicians should use needle thoracostomy as the primary strategy for pleural decompression of tension pneumothorax in most cases. EMS clinicians should take a patient-individualized approach to performing needle thoracostomy, influenced by factors known to impact chest wall thickness and risk for iatrogenic injury. Simple thoracostomy and tube thoracostomy may be used by highly trained EMS clinicians in select clinical settings with appropriate medical oversight and quality assurance. EMS systems must investigate and adopt strategies to confirm successful pleural decompression at the time thoracostomy is performed. Pleural decompression should be performed for patients with traumatic out-of-hospital circulatory arrest (TOHCA) if there are clinical signs of tension pneumothorax or suspicion thereof due to significant thoraco-abdominal trauma. Empiric bilateral decompression, however, is not routinely indicated in the absence of such findings. EMS clinicians should not routinely perform pleural decompression of suspected or confirmed simple pneumothorax prior to air-medical transport in most situations. EMS clinicians may consider placement of a vented chest seal in spontaneously breathing patients with open pneumothoraces. In patients receiving positive pressure ventilation who have open pneumothoraces, chest seals may be harmful and are not recommended. EMS physicians play an important role in developing curricula and leading quality management programs to both ensure that EMS clinicians are properly trained in the recognition and management of tension pneumothorax and to ensure that interventions for tension pneumothorax are performed appropriately, safely, and effectively.