Prehospital needle thoracostomy and the need to implement objective criteria for intervention: A retrospective study.

ABSTRACT OBJECTIVES Tension pneumothorax is treated by performing a needle decompression or simple thoracostomy. Failures with needle decompression include incorrect identification of landmarks, body habitus, inserting the needle too deep or not deep enough. Recently, the use of simple thoracostomy has been increasing in frequency by both air medical and ground-based emergency medical services (EMS) systems. The objective of this study is to compare the effectiveness of needle decompression to simple thoracostomy in a theoretical tension pneumothorax created in a cadaveric model. METHODS We used a prospective, simulation-based experimental crossover study design utilizing fresh, never-frozen human cadavers to determine the differences between needle decompression and simple thoracostomy for the treatment of tension pneumothorax. A theoretical tension pneumothorax was created by placing a catheter into the pleural space and connecting a three-way stopcock, digital manometer, and inflation bulb. A 10-gauge decompression needle was introduced into the chest. Next, after reinflation a simple thoracostomy was performed on the cadaver. The manometer was monitored in both instances to determine if the tension pneumothorax was relieved completely. RESULTS Needle decompression successfully resolved the tension pneumothorax in 29/38 attempts (76.3%), and simple thoracostomy successfully resolved the tension pneumothorax in 35/38 attempts (92.1%) to a value of less than 4 mmHg. Needle decompression completely relieved the intrapleural pressure to a value of 0mmHg in 11/38 attempts (28.9%) and simple thoracostomy relieved the intrapleural pressure to a value of 0mmHg in 23/38 attempts (60.5%); p = 0.004. The mean time to cessation of air release with needle decompression was 34.1 ± 22.2 seconds; the mean time to cessation of air release with simple thoracostomy was 11.9 ± 11.4 seconds; p < 0.001. CONCLUSIONS Simple thoracostomy was successful in 92.1% of the attempts to relieve the tension pneumothorax, whereas needle decompression was successful in 76.3% of the attempts. Simple thoracostomy was also faster at relieving the tension pneumothorax completely, although this is of undetermined significance. All of these results are based on a theoretical tension pneumothorax cadaveric model. EMS clinicians should still maintain a reasonable level of suspicion for unrelieved tension pneumothorax after performing a needle decompression on trauma patients.

Tension pneumothorax is a rapidly fatal but pre ventable cause of death. Needle thoracostomy remains the first-line intervention, yet misplaced catheters fail to relieve pressure and may prolong hypoxia, resulting in cardiovascular compromise and potentially causing injury. This study evaluated the utility of a novel colorimetric capnography device (Capnospot™) designed to provide visual confirmation of pleural entry during decompression. Two swine models of tension pneumothorax were created using transdiaphragmatic CO2 insufflation. After each induction, either needle or pigtail thoracostomy was performed. Time to Capnospot® color change was compared with ultrasound and radiographic confirmation using the Wilcoxon signed-rank test. Twenty-four thoracostomies were performed. Time to colorimetric capnography change for needle thoracostomy was shorter than time to ultrasound confirmation (1,030 vs. 7,030 milliseconds (ms), P=.004). Time to color change was shorter than both the time to X-ray confirmation (1,030 vs. 9,435ms, P=.002) and ultrasound confirmation for pigtail thoracostomy placement (355 vs. 22,355ms, P=.002). Colorimetric capnography provided rapid, reliable confirmation of thoracostomy placement, outperforming both ultrasound and X-ray in speed and accuracy. This technology may streamline decompression in both prehospital and in-hospital settings, reducing complications and delays in life-saving care.

Pleural effusions can be manifestations of heart failure, pulmonary embolism, infection, and malignancy. Symptom assessment, imaging, and pleural fluid analysis serve as key determinants in guiding clinical management. We present the case of a 75-year-old woman with a history of heart failure who developed worsening dyspnea and lower extremity edema. Initial imaging revealed a large unilateral pleural effusion, initially presumed to be secondary to heart failure exacerbation. Pleural fluid analysis demonstrated a discordant exudative effusion by Light's criteria. Following thoracentesis, the development of a tension pneumothorax improved radiographic clarity, revealing previously obscured metastatic osseous lesions that had been masked by the pleural effusion and adjacent lung parenchyma on prior imaging. This prompted further advanced cytologic evaluation which identified dysplastic breast ductal epithelial cells consistent with a malignant pleural effusion. This case underscores the importance of maintaining a broad differential diagnosis, even when pleural fluid analysis is only marginally exudative. Moreover, the occurrence of tension pneumothorax facilitated the identification of occult metastatic lesions, highlighting the essential role of post-procedural imaging in detecting concealed malignancy. This case further emphasizes that even mildly positive exudative effusions necessitate comprehensive investigation for malignancy, as subtle presentations may still indicate significant underlying pathology.

IntroductionIn low- and middle-income countries (LMICs) like Ghana, junior doctors - house officers and medical officers - serve as the primary frontline providers of emergency care, often in resource-limited settings. Despite their critical role, emergency medicine (EM) training in undergraduate and housemanship curricula remains non-standardized. This study conducted a bottom-up training needs assessment to identify clinical and procedural gaps among junior doctors in Ghana.MethodsA cross-sectional digital survey was conducted among 75 junior doctors (house officers and medical officers with not more than five years of practice) between October and December 2018. Using 5-point Likert scales, participants self-assessed their comfort with life-saving procedures and their confidence in managing acute medical and trauma presentations. Data were analyzed using descriptive statistics and thematic categorization of qualitative responses.ResultsAlthough 40% (n = 30) of participants reported managing emergencies “always” in their current roles, only 17.8% (n = 13) felt extremely comfortable as the first-on-call to attend to an emergency or acutely ill patient. While comfort was high for basic tasks like venipuncture (85.9%), it was critically low for advanced procedures; only 8.9% felt comfortable with chest tube insertion, and 87.5% had never performed defibrillation. Confidence was high for managing asthma (90.6%) and hypertensive emergencies (85.0%), but significantly lower for peri-arrest conditions like bradyarrhythmias (70.8% low confidence) and tension pneumothorax. Only 13.5% felt medical school provided excellent preparedness for emergency care, while 100% expressed interest in regular simulation-based training.ConclusionA profound mismatch exists between the clinical responsibilities and the formal emergency care training of junior doctors in Ghana. These findings have informed the development of targeted simulation-based training initiatives and have strengthened the case for mandatory EM integration into undergraduate and housemanship curricula across Ghana. To bridge this gap nationally, we recommend that EM be transitioned from an optional to a mandatory component of undergraduate and housemanship training, integrated with decentralized simulation-based medical education.

Failure to improve after initial management in infants with suspected foreign body aspiration and apparent tension pneumothorax should prompt reconsideration of the diagnosis, including underlying congenital lung anomalies such as CPAM.

Tension pneumothorax in children, although infrequently encountered, requires management with a high level of confidence and skill from the attending physician. Despite this, recommendations on location and needle length for needle thoracostomy (NT) in paediatric patients are not well-established. We therefore aimed to (1) identify how age, sex and body anthropometry affect chest wall thickness (CWT) at common NT landmarks and (2) determine the adequacy of needle lengths used. A retrospective review was undertaken of chest CT scans performed on children aged 0-17 years at KK Women's and Children's Hospital in Singapore. Patients were categorised as infants (<1 year old), children (1-9 years old) and adolescents (10-17 years old). Bilateral CWT at the second intercostal space (ICS) mid-clavicular line (MCL) and fourth ICS mid-axillary line (MAL) were measured radiographically. Adequacy of needle length is defined as CWT < needle length in >95% of cases. 588 CT scans (192 infants, 224 children, 172 adolescents) were reviewed. Mean CWT at the second ICS MCL was 12.61 mm (SD±4.14 mm), 15.62 mm (SD±4.88 mm) and 26.64 mm (SD±11.48 mm) for infants, children and adolescents, respectively. Mean CWT at the fourth ICS MAL is 14.95 mm (SD±5.25 mm), 16.49 mm (SD±5.89 mm) and 28.20 mm (SD±11.53 mm) for infants, children and adolescents, respectively. Adequate needle length was 25 mm, 32 mm and 50 mm for infants, children and adolescents, respectively, when inserted at the second ICS MCL. In a Singaporean population, mean CWT at the second ICS MCL is thinner than mean CWT at the fourth ICS MAL for all age, sex, weight-for-length and body mass index categories. For successful NT at the second ICS MCL, a 25 mm needle is recommended for infants, 32 mm for children and 50 mm for adolescents.

Esophageal stricture is the most frequent caustic ingestion sequela, leading to dysphagia and malnutrition. The colon is the most commonly used graft for esophageal reconstruction. The most dreadful early complication of colonic interposition is leakage of cervical esophagocolic anastomosis, which can be caused by several factors. Tension pneumothorax has never been reported in the medical literature. A 5year-old Black African male patient with retrosternal pain and dysphagia was admitted to the department of surgery. The patient had a history of accidental caustic soda powder ingestion 12weeks ago. Examination of the ear, nose, and throat; thorax; and abdomen revealed normal findings. A preoperative upper gastrointestinal barium swallow test revealed cervical esophageal stenosis and a long thoracic esophageal stricture. Esophagocoloplasty was performed after transhiatal resection of the native esophagus using a transverse colon placed in the posterior mediastinum. The postoperative course was characterized by an enterocutaneous fistula 2days after surgery. A postoperative upper gastrointestinal barium swallow test revealed a cervical esophagocolic anastomotic leak associated with left-side tension pneumothorax. Left pleural drainage was performed. Cervical esophagocolic anastomotic leakage stopped 2days after pneumothorax drainage, and the fistula healed early. This clinical evolution suggests that the fistula was caused by the compressive pneumothorax-induced deviation of the interposed colonic segment. The 2-year follow-up showed no complications. Leakage of cervical anastomosis is the most common complication of esophageal reconstruction surgery. Many factors influence the occurrence of leakage. To the best of our knowledge, this is the first case of cervical anastomosis leakage due to a tension pneumothorax.

IntroductionGlobal health experiences (GHEs) are increasingly popular among medical trainees. Predeparture training is crucial in preparing learners for the challenges of working in low- and middle-income countries (LMICs). However, few resources are tailored to training level or specialty. This simulation-based course was designed to enhance emergency medicine (EM) trainees’ preparedness for GHEs in LMICs.MethodsA 4-hour course consisting of 5 small-group simulations followed by a large-group summative lecture designed to reinforce case scenarios was presented to EM residents and medical students. Topics were chosen to represent common, high-acuity conditions in LMICs (e.g., multiple blunt-force trauma, postpartum hemorrhage, pericardial tamponade secondary to tuberculosis, cerebral malaria, intentional organophosphate poisoning). To mirror resource-constrained environments, learners managed each simulated case using limited equipment, diagnostic tools, and medications. A critical action checklist ensured that simulation educational objectives were achieved, and a postcourse survey assessed perceived relevance, realism, and impact on confidence.ResultsSixteen EM residents and 4 medical students participated. While most learners had previous experience managing postpartum hemorrhage and tension pneumothorax (each 75%), fewer had experience managing pulmonary tuberculosis (25%), malaria (25%), or organophosphate poisoning (15%). Following training, 80% supported inclusion in the residency curriculum annually. Most participants strongly agreed that the training increased confidence in practicing EM in LMICs. Confidence improved in handling all conditions, with the highest increases in confidently managing postpartum hemorrhage and organophosphate poisoning.DiscussionThis EM-specific, simulation-based global health course was well-received and effectively enhanced participants’ confidence and preparedness for GHEs.

Pleural Manometry in Pneumothorax: Evaluating Tension Physiology and Predicting Outcomes.

Introduction: Tension pneumopericardium (tPPC) is a rare diagnosis - a collection of air within the pericardial sac causing cardiac tamponade and subsequent circulatory collapse. TPPC is a life-threatening and important diagnosis to consider during initial evaluation of a blunt thoracic trauma. PPC can be diagnosed on chest x-ray but is often not present or appreciated until after CT scan. Despite emergent treatment with pericardiocentesis or pericardial window, PPC remains a negative predictor for mortality. Description: A 30 year old male motorcyclist presented as a Level one with a right tension pneumothorax. He underwent rapid sequence intubation and placement of a right chest tube. Initial FAST was negative but upon CT imaging, PPC/pneumomediastinum and a left hemo/pneumothorax were identified, and a left chest tube was placed. Due to refractory hypotension, CT surgery was STAT consulted and patient was taken emergently to the operating room for pericardial window and drain placement. Post operatively, his hemodynamics stabilized and pericardial drain was removed on postop day 1. Postop days 7 to 10, the chest tubes were consecutively placed to water seal and removed. The patient was extubated to Optiflow on hospital day 12 and discharged to rehab on hospital day 22. Discussion: Although our patient’s right pneumothorax was addressed expeditiously, his course was complicated by development of tPPC. Despite a documented mortality rate of 58% for tPPC (Cummings et al), our patient was treated with a pericardial window and drain, recovered, and was eventually discharged. Nasr et al. reports cure rates in traumatic PPC patients of 45% with thoracostomy and 23% after operative intervention. PPC’s elevated mortality rate suggests that further education is needed on common presentations, symptoms, and risk factors to look out for not only on initial trauma evaluation, but more importantly after, as it has been noted to take an hour for tension pathology to develop from PPC. Close monitoring of hemodynamic stability, acute changes in presentation and careful assessment of imaging are all paramount in detecting the progression of PPC to tPPC. Thus, a high index of suspicion should be maintained throughout the trauma assessment for the development of tPPC to improve clinical outcomes.

Introduction: Nepal faces significant challenges in addressing trauma-related injuries, with falls, road traffic accidents, and burns being the leading causes of injury. A pilot study evaluated emergency care capacity at tertiary hospitals in Kathmandu, Nepal, using the World Health Organization’s (WHO) newly deployed Hospital Emergency Unit Assessment Tool (HEAT). A focused secondary analysis of the HEAT tool results was conducted to assess emergency trauma capacity. Methods: This cross-sectional mixed-method study uses the WHO HEAT Tool to assess resources for trauma care delivery through descriptive statistics and comparative analysis. The tool combines open-ended questions, scaled responses, and discrete answers to evaluate facility signal functions, focusing on “trauma interventions” and signal functions that reflect emergency trauma care capacity. Results: Across all sites (n=7), an average 6.6 out of 10 trauma interventions were adequately available. All sites had adequate availability of resources for endotracheal intubation, bag-valve-mask ventilation, and oxygen saturation monitoring. Three sites reported adequate availability of mechanical ventilation but only one site had adequate availability of rescue surgical airway procedures. All sites reported adequate availability of needle decompression for tension pneumothorax and placement of tube thoracostomy. Only 1 out of 7 sites had interosseous access, while 4 had central venous access. All sites reported adequate availability of external hemorrhage control, wound packing, and suturing. Five sites reported adequate availability of pelvic binders. None of the sites reported utilizing the WHO Trauma Care checklist. Conclusion: Integrating trauma care-related questions into the HEAT tool was a feasible methodology for assessing strengths and identifying critical gaps in trauma care delivery in Nepal. Major gaps were identified in care, such as capacity for rescue surgical airway procedures, mechanical ventilation, and utilization of trauma care checklists. Further validation of this tool in application to emergency trauma care can improve trauma care delivery in resource-limited settings like Nepal.

Summary: Cooper University Health Care’s Section of Military, Diplomatic &amp; Field Surgical Affairs (MILDAF), in conjunction with members of Cooper’s Trauma, Surgical, and Emergency Departments as well as the Salem County, New Jersey’s Sheriff’s Office and Office of Emergency Management developed a model for Tactical Trauma Training for all levels of Law Enforcement, EMS, and Fire/Rescue members. In April 2024, more than 275 law enforcement, EMS providers, firefighters, and rescue personnel from New Jersey, Pennsylvania, Delaware, and New York attended the week-long Mid-Atlantic Severe Situation Exercise (MASSE), which focused on point-of-injury management for emergency responders. This exercise provided high-fidelity training with cadavers within simulated settings of real-world situations. Events such as MASSE serve to develop and improve life-saving skills for first responders to ensure preparedness in the face of unpredictable, complex, and dangerous real-life crises. Scenarios at the MASSE training event included farm vehicle accidents, man-in-the-machine incidents, domestic violence, hostage situations, and an austere location medical intervention lab. First responders in attendance gained new skills to better equip them to deal with potential real-world situations and save lives. Participants learned proper tourniquet placement from US Army medical personnel embedded at Cooper. Participants also received hands-on training from surgeons in the cadaver lab. Cadaver lab topics included emergent airway maneuvers, intra-osseous vascular access, needle decompression of tension pneumothorax, and arterial bleeding control techniques in both extremity and junctional wounds. Instructors then challenged participants to use these skills in three unique live-fire scenarios and then provided immediate actionable feedback in a tactical and medical debrief. By pooling resources and expertise, MASSE serves to improve the skills of local first responders and EMS, thereby enhancing public safety. The MILDAF team and their partners look forward to continually improving and executing high-fidelity hands-on training.

Management of spontaneous pneumothorax often involves intercostal chest drain (ICD) insertion. Determining when to remove the ICD is controversial, with significant variation in practice. Establishing optimal ICD management in pneumothorax could reduce morbidity and improve cost-effectiveness. Do ICD removal strategies, including clamping and use of digital air leak devices, impact the risk of pneumothorax recurrence, need for repeat pleural procedures, or length of stay? We conducted a multicenter retrospective analysis of patients requiring ICD insertion for spontaneous pneumothorax from May 2021 to October 2023. Data were collected on demographics, clinical course, ICD removal strategy, pneumothorax recurrence (early and late), and repeat pleural intervention. A total of 791 admissions from 27 centers were included. The 30-day recurrence of pneumothorax was 13.0% (n = 103). Clamping trials were undertaken in 32.6% of cases (n = 258), but recurrence of pneumothorax was not significantly different in clamped compared with nonclamped groups (14.0% vs 12.6%, respectively; P = .67). Clamping identified pleural air reaccumulation in 24 episodes (9.3% of the clamped group). Of 234 cases where clamping did not identify air leak, 35 patients (15.0%) developed recurrent pneumothorax. Of the 533 patients whose drains were not clamped, 67 (12.6% of the group) developed recurrence. The median length of stay was 6 (clamped) vs 5 days (nonclamped) (P = .08). Adverse events associated with clamping were few (n = 6), but included tension pneumothorax (n = 1). Digital air leak devices combined with clamping resulted in the lowest rates of pneumothorax recurrence; however, this approach was rare (n = 24, 0.0% recurrence within 7 days). Our results indicate that recurrent pneumothorax after ICD removal is a common complication. Clamping trials are safe but do not appear to be associated with reduced rates of recurrent pneumothorax. An ultracautious approach using digital air leak devices in combination with clamping could represent a viable strategy in selected patients.

The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.

For infected wounds, including clostridial myonecrosis, necrotizing soft tissue infections, and Fournier's gangrene, hyperbaric oxygen therapy (HBOT) is advised; however, tension pneumothorax and gas emboli may occur during the process. Other instances of relative contraindications include illnesses like asthma and chronic obstructive lung disease. We can use radio frequency and strong pulsed light in our research without having to worry about these kinds of issues and could have a significant impact on improving treatment outcomes. To assess how well intensely pulsed light and radiofrequency work for treating the aftereffects of post-Fournier's gangrene. Intense pulsed light and radiofrequency sessions were used to treat sixteen male patients with isolated penile or scrotal post-Fournier's gangrene raw areas. Twelve patients (75%) had an excellent satisfaction rate, and four (25%) rated it as good. No fair or poor results were documented. We are unable to make significant conclusions because of the small number of patients; however, since E-light is a simple, effective, and affordable treatment with good outcomes and no side effects, we advise more research on its application in the treatment of post-Fournier's gangrene isolated raw areas of the scrotum and penis.

Tension pneumothorax (tPTX) is a life-threatening but treatable condition in combat environments, where survivability depends on rapid and accurate needle chest decompression (NCD). However, prior research shows a notable gap between clinical knowledge and hands-on procedural skills, with NCD site selection accuracy as low as 26.1% among military medics. This study's purpose was to evaluate the overall accuracy of NCD site selection among active duty military medical professionals in a novel, simulated high-stress combat environment. This study aimed to determine if environmental stressors affect procedural accuracy and to identify potential training deficiencies. This prospective, randomized controlled trial (RCT) was approved by the Naval Medical Center San Diego (NMCSD) Institutional Review Board (IRB). We randomized 75 military medical professionals into a control group (well-lit, quiet room) and a high-stress group (darkened room with red light and auditory distractions). Participants were tasked with marking the 4 designated NCD sites (second intercostal space, midclavicular line and fifth intercostal space, anterior axillary line, bilaterally) on 6 live male models. We defined accuracy as a mark falling entirely within a predetermined 6 cm by 2 cm zone. We used Welch's 2-sample t-tests and linear regression to analyze accuracy data, and a Wilcoxon Signed-Rank test to compare the perceived ease of site selection. The study found no statistically significant difference in overall NCD site selection accuracy between the high-stress and control groups (P = .7), with both groups achieving a low average accuracy of 31%. However, a significant difference was observed between the 2 anatomical sites, with accuracy at the 2ICS being substantially higher (41%) than at the 5ICS (21%) (P < .001). Participants reported no significant difference in the perceived ease of locating the 2 sites (P = .105), revealing a gap between self-perception and actual performance. We also found that real-life NCD experience was a significant predictor of overall accuracy (P = .044), though this finding is limited by the small number of participants with this experience (n = 2). A simulated high-stress environment did not affect NCD site selection accuracy in this population. The significant difference in accuracy between the 2 sites, combined with the lack of difference in perceived ease, suggests that current Tactical Combat Casualty Care (TCCC) training may be inadequate, particularly for the 5ICS site. Our study's strengths include its randomized design and the use of live models, but it is limited by its single-center recruitment and the small sample size for real-life experience. These results underscore a critical need for improved hands-on training methods, such as cadaver-based learning, to ensure military medical professionals can competently perform NCD under all conditions. Future studies should explore the impact of different training methods and the influence of body habitus on site selection accuracy.

This report presents a rare case of pneumorrhachis, pneumothorax, and pneumocephalus in a patient with multiple traumatic injuries following a gunshot wound to the chest. Pneumorrhachis, the presence of air within the spinal canal, can arise from iatrogenic, nontraumatic, or traumatic causes and is classified as extradural or intradural, the latter often linked to severe trauma. Pneumothorax, air in the pleural space, may impair ventilation and presents as simple, communicating, or tension types, with causes including trauma, iatrogenesis, or spontaneous events. Pneumocephalus, an accumulation of gas within the neurocranium, typically resolves spontaneously but rarely occurs in combination with pneumothorax after thoracic gunshot trauma. This report aims to elucidate the potential pathophysiological mechanisms of air migration and highlight the multidisciplinary management challenges inherent in this rare traumatic triad. A 45-year-old Syrian male presented with multiple traumatic injuries following a gunshot wound to the chest. Initial assessment revealed respiratory distress, hemodynamic instability, and decreased oxygen saturation. Clinical evaluation and imaging confirmed a tension pneumothorax, which was treated with an emergent chest tube placement. Subsequent computed tomography scans showed extensive pneumocephalus, with air pockets in the intracranial cavity, and pneumorrhachis, with air tracking along the spinal canal. Both findings were attributed to the high-pressure air leakage through fascial planes and anatomical pathways caused by the penetrating trauma. The patient was managed with supplemental oxygen, careful neurological monitoring, and supportive care. Despite the severe injuries, his condition stabilized, and no surgical intervention was required for the pneumorrhachis or pneumocephalus, which resolved spontaneously over time. However, the patient's clinical course was complicated by persistent infection and respiratory failure, and he ultimately succumbed to his injuries 3 months after admission. The coexistence of pneumorrhachis, pneumothorax, and pneumocephalus following chest gunshot trauma is exceedingly rare. This case underscores the importance of early recognition, prompt imaging, and multidisciplinary care in managing such complex injuries, contributing valuable insights to the limited literature on these conditions.

During laparoscopic surgery, tension pneumothorax may persist despite prompt anatomical repair of a diaphragmatic injury, posing a diagnostic and management challenge for anesthesiologists under general anesthesia. A 68-year-old male undergoing bilateral laparoscopic adrenalectomy using a retroperitoneal approach developed progressive hypoxemia, hypercapnia, elevated peak inspiratory pressure, and hemodynamic instability approximately 4 h after surgical initiation. A minor diaphragmatic injury was identified and immediately repaired after reduction of pneumoretroperitoneum. Despite anatomical correction, respiratory and circulatory instability persisted, requiring high-dose vasopressor support and 100% inspired oxygen until the end of surgery. A radiograph obtained at the conclusion of surgery demonstrated marked mediastinal shift consistent with tension pneumothorax. The pneumothorax resolved spontaneously with supportive ventilation, and the patient recovered without chest tube insertion. This case highlights a physiological pitfall rather than a rare complication: even a minor diaphragmatic injury can result in sustained tension physiology despite timely anatomical repair during prolonged laparoscopic surgery. Continuous vigilance for evolving physiological abnormalities and proactive anesthesiologist-led management are essential.

Prehospital Management of Traumatic Cardiac Arrest: A Narrative Review of Evidence and Implications for Emergency Nursing.