Elsevier

Resuscitation

Volume 72, Issue 1, January 2007, Pages 11-25
Resuscitation

Review article
Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review

https://doi.org/10.1016/j.resuscitation.2006.06.025Get rights and content

Summary

Pre-hospital insertion of chest tubes or decompression of air within the pleural space is one of the controversial topics in emergency medical care of trauma patients. While a wide variety of opinions exist medical personnel on the scene require guidance in situations when tension pneumothorax or progressive pneumothorax is suspected. To ensure evidence based decisions we performed a systematic review of the current literature with respect to the diagnostic accuracy in the pre-hospital setting to identify patients with (tension) pneumothorax, the efficacy and safety of performing pleural decompression in the field and the choice of method and technique for the procedure. The evidence found is presented and discussed and recommendations are drawn from the authors’ perspective.

Introduction

Pre-hospital insertion of chest tubes or decompression of air within the pleural space is one of the controversial topics in emergency medical care of trauma patients. There is a wide variety of opinions, ranging from complete disapproval as quoted from K. Mattox in the trauma.org discussion forum a few years ago: “There is indeed a lot of emotion relating to the ability to perform a technical assault on a patient, including needle decompression in the field. I have found NO, I repeat NO, data which were prospectively collected in a randomised fashion which justifies this dangerous practice. I would strongly recommend that pre-hospital chest decompression by ANYONE by any method be eliminated until appropriate evidenced based data exist”1 to the recommendation in a recent review that pleural decompression would be life saving standard care: “The pre-clinical tension pneumothorax which, even without technical support, is easily recognisable, requires immediate decompression. However, there are a number of patients with thoracic injuries such as serial rib fractures or palpable skin emphysema which may necessitate the insertion of a thoracic tube”.2 The discussion mainly focuses around the ability to identify patients with (tension) pneumothorax reliably, the efficacy and safety of performing pleural decompression in the field and the choice of method and technique for the procedure, i.e. needle decompression, chest tube insertion or others. As is the case with many problems in pre-hospital emergency medicine, there is little evidence available in terms of randomised trials or high quality prospective studies. In this systematic review we evaluated the available medical literature describing the present knowledge of pre-hospital chest tube placement and pleural decompression after blunt trauma so that pre-hospital medical personnel may decide on their choice of treatment.

Section snippets

Methods

The literature search was primarily done in Medline as indicated in Table 1 (last update from November 16, 2005). There were 638 hits, which were all screened in abstract form. Potentially relevant articles were acquired in full text. In addition, the reference list of all publications seen in full text was reviewed for potentially relevant citations not found with the data bank search. The search was completed by a hand search of books and journals not indexed in Medline.

All relevant articles

Clinical examination

Scientific evidence is not available to determine whether pre-hospital clinical examination is necessary, or not, to improve outcome of patients with potential trauma to the chest. However, physical examination is a pre-requisite for all decisions about medical management of patients and this opinion has never been challenged.

Assuming that some kind of pre-hospital examination is useful in this setting, there are several publications suggesting what should be looked for. These focus on

Conflict of interest

There is no conflict of interest involved by any of the authors.

Acknowledgements

We thank the members of the Arbeitsgemeinschaft Notfallmedizin der Deutschen Gesellschaft für Unfallchirurgie (Task Force on Emergency Medicine of the German Trauma Association) for their invaluable input and advice during many hours of discussions.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2006.06.025.

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