A/Prof. Alan Garner1, Ms Elwyn Poynter1, Dr Ruth Parsell1, Dr Andrew Weatherall1, Dr Mary Morgan2, Professor Anna Lee3
1CareFlight, Northmead, Australia, 2Hunter Retrieval Service, Newcastle, Australia, 3Chinese University of Hong Kong, Shatin, Hong Kong SAR
Purpose and issue under consideration
We sought to compare the complication rates of needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline Kits and endotracheal tubes), and to determine if finger thoracostomy is associated with shorter prehospital scene times and lower infection rates compared with tube thoracostomy.
Methods
In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure, over a 75 month period. Comparisons of complication rates for needle, finger and tube thoracostomy, and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complication and length of scene time by decompression technique.
Outcome
Two hundred and fifty-five patients underwent 383 decompression procedures; 58 patients having one complication, and two patients had two complications. Finger thoracostomy was associated with a lower adjusted risk of overall complication (RR 0.59, 95% CI: 0.38-0.94) although tube complications were largely technical malpositions without evidence the tube was unable to maintain decompression. Re-tension however was more frequent with finger thoracostomy compared with tube thoracostomy (13.9% vs 3.2%, P < 0.001). Adjusted median prehospital time was shorter for patients undergoing finger vs tube thoracostomy (38 vs 43mins, P = 0.030), whereas infective complication rates were similar (2.7% vs 2.1%, P =0.85).
Conclusions
Overall complication rates were lower with finger thoracostomy, but the risk of re-tension was significantly higher. Therefore, tube thoracostomy is recommended where episodes of hypoxia and hypotension should be avoided such as patients with severe traumatic brain injury. Finger thoracostomy was not associated with lower infection rates but was associated with shorter adjusted prehospital times in services with the same role delineation.
Biography:
Alan Garner is a specialist emergency physician with specialisation in prehospital and retrieval medicine. He completed a doctorate in the prehospital management of severe trauma by physician staffed helicopter services and was the chief investigator or a $20m research trial examining the effect of prehospital physician care on patients with severe head injury. Alan was National Medical Director of CareFlight for 15 years. He was awarded the Order of Australia Medal (OAM) for services to retrieval and disaster medicine, a Clinical Associate Professor, Nepean Clinical School, University of Sydney and Chief Innovation Officer for CareFlight.