Elsevier

Injury

Volume 45, Issue 1, January 2014, Pages 71-76
Injury

Improvement in the prehospital recognition of tension pneumothorax: The effect of a change to paramedic guidelines and education

https://doi.org/10.1016/j.injury.2013.06.010Get rights and content

Abstract

Introduction

An audit of ambulance service clinical records from 2001 to 2002 in Melbourne, Australia revealed 10 patients with tension pneumothorax on arrival at hospital which had been undetected or untreated by paramedics. The clinical practice guideline for paramedic recognition of tension pneumothorax was subsequently changed to emphasise heightened clinical suspicion of a tension pneumothorax in the setting of chest trauma, especially when patients were managed with positive pressure ventilation.

This study was undertaken to determine whether the number of undetected or untreated tension pneumothoraces had decreased after the new clinical practice guideline and associated education program; if there were unintended consequences arising from earlier paramedic intervention; and what effect, if any, this change had on subsequent hospital treatment.

Methods

Retrospective case note review of all patients requiring intercostal catheter (ICC) insertion at The Alfred Hospital, Melbourne, Australia, using records from Ambulance Victoria, the Alfred Trauma Registry and the National Coronial Information System.

Results

In 2001–2002 paramedics treated 22 patients with suspected tension pneumothorax before transport to the Alfred Hospital. In 2006–2007 this number had increased to 81. There was a decrease from ten to four in the number of unrecognised or untreated tension pneumothoraces between the two time periods. No unintended or adverse consequences of prehospital needle decompression could be found. However, there was an increase in the number of patients who had prehospital needle decompression that needed further treatment for tension pneumothorax on arrival at hospital. This need for further treatment was associated with use of shorter cannulas and unilateral needle decompression by paramedics.

Conclusion

A small change in clinical practice guidelines, supported by an education and audit program, led to a reduction in unrecognised untreated tension pneumothoraces by paramedics without an increase in complications. Paramedics should be aware that a shorter cannula may fail to reach the pleural space and that both sides of the chest may require decompression.

Introduction

The management of tension pneumothorax in the prehospital environment is controversial. Tension pneumothorax is a relatively uncommon condition; however, it can lead to death if untreated and is responsible for a significant number of preventable deaths.1 The condition is usually encountered by paramedics, and hospital staff in the Emergency Department, Operating Theatre and Intensive Care Unit.2

In 2004 Heng et al. published a study examining intercostal catheter (ICC) insertion in trauma patients admitted to The Alfred Trauma Centre in Melbourne, Australia.3 That study reported that 10 patients transported by paramedics over the 12-month study period had an untreated tension pneumothorax on arrival at hospital.3

In 2005, the Medical Standards Committee of Ambulance Victoria (AV) approved minor changes to the Clinical Practice Guidelines (CPGs) as a result of these findings, and understanding that the “classic” clinical signs of a tension pneumothorax may not always be present or readily detected in the field.2 These CPGs are used by Mobile Intensive Care (MICA) Paramedics to guide their practice in the management of a patient presenting with suspected tension pneumothorax. These changes were supported by a clinical education program and audit process.

After these CPG changes more patients underwent needle decompression whilst in the care of MICA Paramedics. However, it was not clear how safe and effective this revised guideline was.

The aims of this study were to:

  • 1.

    Compare the number of needle decompressions by MICA Paramedics in 2006–2007 to 2001–2002 and the number of unrecognised/untreated patients admitted to The Alfred Trauma Centre and;

  • 2.

    Identify any unintended adverse consequences arising from the revised CPG and the clinical practice of MICA Paramedics in 2006–2007.

Section snippets

Setting

Victoria is in the south east region of Australia with a population of 5.5 million people; the capital and major city is Melbourne with a population of 4 million people. The Alfred Hospital is one of Melbourne's two adult trauma centres. The Alfred Hospital receives approximately half of Victoria's adult major trauma patients (>1000 major trauma patients per year). AV is the single, publicly funded, state-wide emergency ambulance service which is the primary provider of prehospital emergency

Case definition of untreated tension pneumothorax on arrival at hospital

There are no reliable published data on the incidence of tension pneumothorax in the setting of chest trauma. Definitions of tension pneumothorax across jurisdictions are likely to vary as the presence of the condition is a clinical diagnosis.

For the purposes of the study, any pneumothorax which was treated with ICC insertion within 15 min of arrival at hospital was considered a potential case. ICC insertion within 15 min of arrival at hospital was chosen as the cut off for cases as early

Results

During the period of 2001–2002, 740 patients with major trauma were taken to the Alfred Hospital, by 2006–2007 this had increased to 1034 patients. The age, sex and ISS of the patients were similar.

During 2001–2002 32 patients required prehospital needle decompression for a suspected tension pneumothorax, of which 22 patients received needle decompression by MICA paramedics. In 2006–2007 85 patients with major trauma required prehospital needle decompression, of which 81 patients received this

Discussion

This study has shown clear improvement in the prehospital recognition of potential tension pneumothoraces in the setting of traumatic chest injury. Following the change to clinical practice and education, the number of cases requiring urgent ICC insertion for unrecognised tension pneumothorax on arrival at hospital fell significantly from 10 cases to 4 cases. The emphasis on an increased suspicion of tension pneumothorax in intubated patients also resulted in increased needle decompression in

Limitations

There are several limitations to this study.

This is a retrospective case series review using records from AV, The Alfred Trauma Centre, VSTR and the NCIS. Accordingly the study is reliant upon the completeness and accuracy of the routinely collected data. Accurate information about potentially important confounding variables may not have been captured; and establishing a causal link is impossible.

Identification of a possible tension pneumothorax based on the insertion of an ICC within 15 min of

Conclusions

A change in education and clinical practice increased the number of patients receiving needle decompression for a tension pneumothorax. There was a decrease in the number of unrecognised untreated tension pneumothorax patients on arrival at hospital despite an increase in the exposed population. There was an increase in the number of patients who had a tension pneumothorax recognised and treated in the prehospital setting but who still required further treatment on arrival at hospital. This

Funding

This research project was funded by the Victorian Trauma Foundation's Trauma Improvement Program.

Ethics approval

Ethics committee approval for this study was provided by: The Alfred Hospital Ethics Committee and the Victorian Department of Justice Human Research Ethics Committee. Ambulance Victoria (the then Metropolitan Ambulance Service) Research Governance Committee subsequently approved data access.

Conflict of interest

None declared.

Acknowledgements

The authors would like to thank the following people and institutions for their assistance with the original study: The Alfred Hospital. The National Trauma Research Institute. Associate Professor Michael Bailey, School Public Health & Preventive Medicine, Monash University. The Alfred Trauma Registry. MICA Department, Ambulance Victoria. The National Coroners Information System.

References (15)

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