Exsufflation: Attention , éviter le péricarde !

Risk of Harm in Needle Decompression for Tension Pneumothorax
Thompson P et Al.  J Spec Oper Med. 2023 Apr 10;ZU1D-3DL9. doi: 10.55460/ZU1D-3DL9

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Les recommendations américaines sont parfois un peu hâtives. C'est le cas de celles portant sur la longueur préconisée du cathéter d'exsufflation. 

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Comme quoi le "suivisme" évoqué récemment par un homme politique françias n'est pas toujours bon.
Introduction: Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site.

Methods: Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of =30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests.

Results: The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79).

Conclusion: The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

Exsufflation: 14G de 5 cm c'est bon

Needle Thoracostomy: Does Changing Needle Length and Location Change Patient Outcome?

Weichenthal LA et Ql. Prehosp Disaster Med. 2018 Jun;33(3):237-244. 

 

BACKGROUND:

Needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma. The purpose of this study is to compare outcomes, efficacy, and complications after a change in policy related to NT in a four-county Emergency Medical Services (EMS) system with a catchment area of greater than 1.6 million people.

METHODS:

This is a before and after observational study of all patients who had NT performed in the Central California (USA) EMS system. The before, anterior midclavicular line (MCL) group consisted of all patients who underwent NT from May 7, 2007 through February 28, 2013. The after, midaxillary line (MAL) axillary group consisted of all patients who underwent NT from March 1, 2013 through January 30, 2016, after policy revisions changed the timing, needle size, and placement location for NT. All prehospital and hospital records where NT was performed were queried for demographics, mechanism of injury, initial status and post-NT clinical change, reported complications, and final outcome. The trauma registry was accessed to obtain Injury Severity Scores (ISS). Information was manually abstracted by study investigators and examined utilizing univariate and multivariate analyses.

RESULTS:

Three-hundred and five trauma patients treated with NT were included in this study, of which, 169 patients (the MCL group) were treated with a 14-guage intravenous (IV) catheter at least 5.0-cm long at the second intercostal space (ICS), MCL after being placed in the ambulance; and 136 patients (the MAL group) were treated with a 10-guage IV catheter at least 9.5-cm long at the fifth ICS, MAL on scene. The mean ISS was lower in the MAL cohort (64.5 versus 69.2; P=.007). The mortality rate was 79% in both groups.

The multivariate model with regard to survival supported that a lower ISS (P<.001) and reported clinical change after NT (P=.003) were significant indicators of survival. No complications from NT were reported.

CONCLUSIONS:

Changing the timing, length of needle, and location of placement did not change mortality in patients requiring NT. Needle thoracostomy was used more frequently after the change in policy, and the MAL cohort was less injured. No increase in reported complications was noted.

Exsuflation: Plus stable par voie axillaire

Relative device stability of anterior versus axillary needle decompression for tension pneumothorax during casualty movement: Preliminary analysis of a human cadaver model.

Leatherman ML et Al J Trauma Acute Care Surg. 2017 Jul;83(1 Suppl 1):S136-S141

 

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L'étude porte sur la stabilité des cathéters d'exsufflation posés par voie antérieure versus par voie axillaire. Cette dernière voie est associée à un bien moindre risque de délogement pendant un transport que la voie antérieure. Ceci milite pour faire de la voie axillaire la voie de référence, et ce malgré la constatation de lésions parenchymateuses minimes.

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BACKGROUND:

Tension pneumothorax (tPTX) remains a significant cause of potentially preventable death in military and civilian settings. The current prehospital standard of care for tPTX is immediate decompression with a 14-gauge 8-cm angiocatheter; however, failure rates may be as high as 17% to 60%. Alternative devices, such as 10-gauge angiocatheter, modified Veress needle, and laparoscopic trocar, have shown to be potentially more effective in animal models; however, little is known about the relative insertional safety or mechanical stability during casualty movement.

METHODS:

Seven soft-embalmed cadavers were intubated and mechanically ventilated. Chest wall thickness was measured at the second intercostal space at the midclavicular line (2MCL) and the fifth intercostal space along the anterior axillary line (5AAL). CO2 insufflation created a PTX, and needle decompression was then performed with a randomized device. Insertional depth was measured between hub and skin before and after simulated casualty transport. Thoracoscopy was used to evaluate for intrapleural placement and/or injury during insertion and after movement. Cadaver demographics, device displacement, device dislodgment, and injuries were recorded. Three decompressions were performed at each site (2MCL/5AAL), totaling 12 events per cadaver.

RESULTS:

Eighty-four decompressions were performed. Average cadaver age was 59 years, and body mass index was 24 kg/m. The CWT varied between cadavers because of subcutaneous emphysema, but the average was 39 mm at the 2MCL and 31 mm at the 5AAL. Following movement, the 2MCL site was more likely to become dislodged than the 5AAL (67% vs. 17%, p = 0.001).

Median displacement also differed between 2MCL and 5AAL (23 vs. 2 mm, p = 0.001). No significant differences were noted in dislodgement or displacement between devices. Five minor lung injuries were noted at the 5AAL position.

CONCLUSION:

Preliminary results from this human cadaver study suggest the 5AAL position is a more stable and reliable location for thoracic decompression of tPTX during combat casualty transport.

Exsufflation: Gros et grand KT ? Pas sûr

Needle Thoracostomy: Does Changing Needle Length and Location Change Patient Outcome?  

Weichenthal, L. et Al. Prehospital and Disaster Medicine 2018, 33(3), 237-244.

 

Cette publication se caractérise par l'importance de la traumatolgie ouverte. elle n met pas en évidence d'amélioration de la moralité avec le recours à des cathéters 10g de 9 cm par voie axillaire versus les cathéters 14g par voie antérieure.

 

Background

Needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma. The purpose of this study is to compare outcomes, efficacy, and complications after a change in policy related to NT in a four-county Emergency Medical Services (EMS) system with a catchment area of greater than 1.6 million people.

Methods

This is a before and after observational study of all patients who had NT performed in the Central California (USA) EMS system. The before, anterior midclavicular line (MCL) group consisted of all patients who underwent NT from May 7, 2007 through February 28, 2013. The after, midaxillary line (MAL) axillary group consisted of all patients who underwent NT from March 1, 2013 through January 30, 2016, after policy revisions changed the timing, needle size, and placement location for NT. All prehospital and hospital records where NT was performed were queried for demographics, mechanism of injury, initial status and post-NT clinical change, reported complications, and final outcome. The trauma registry was accessed to obtain Injury Severity Scores (ISS). Information was manually abstracted by study investigators and examined utilizing univariate and multivariate analyses.

Results

Three-hundred and five trauma patients treated with NT were included in this study, of which, 169 patients (the MCL group) were treated with a 14-guage intravenous (IV) catheter at least 5.0-cm long at the second intercostal space (ICS), MCL after being placed in the ambulance; and 136 patients (the MAL group) were treated with a 10-guage IV catheter at least 9.5-cm long at the fifth ICS, MAL on scene.

 

 

The mean ISS was lower in the MAL cohort (64.5 versus 69.2; P=.007). The mortality rate was 79% in both groups. The multivariate model with regard to survival supported that a lower ISS (P<.001) and reported clinical change after NT (P=.003) were significant indicators of survival. No complications from NT were reported.

Conclusions

Changing the timing, length of needle, and location of placement did not change mortality in patients requiring NT. Needle thoracostomy was used more frequently after the change in policy, and the MAL cohort was less injured. No increase in reported complications was noted.

Exsufflation: 5 cm antérieur survie = 9 latéral

Needle Thoracostomy: Does Changing Needle Length and Location Change Patient Outcome?

 

Weichenthal LA et Al. Prehosp Disaster Med. 2018 Jun;33(3):237-244

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Un travail aux résultats qui interpellent. Il compare 2 pratiques (exsufflation antérieure avec un KT de 5 cm et exsufflation latérale avec un KT de 9 cm) et qui ne met pas en évidence d'avantage à l'emploi de cathéter d'exsufflation de grande longueur en terme de survie. Pour rappel l'exsufflation au doigt doit rester la référence (Lire la fiche memento)

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BACKGROUND:

Needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma. The purpose of this study is to compare outcomes, efficacy, and complications after a change in policy related to NT in a four-county Emergency Medical Services (EMS) system with a catchment area of greater than 1.6 million people.

METHODS:

This is a before and after observational study of all patients who had NT performed in the Central California (USA) EMS system. The before, anterior midclavicular line (MCL) group consisted of all patients who underwent NT from May 7, 2007 through February 28, 2013. The after, midaxillary line (MAL) axillary group consisted of all patients who underwent NT from March 1, 2013 through January 30, 2016, after policy revisions changed the timing, needle size, and placement location for NT. All prehospital and hospital records where NT was performed were queried for demographics, mechanism of injury, initial status and post-NT clinical change, reported complications, and final outcome. The trauma registry was accessed to obtain Injury Severity Scores (ISS). Information was manually abstracted by study investigators and examined utilizing univariate and multivariate analyses.

RESULTS:

Three-hundred and five trauma patients treated with NT were included in this study, of which, 169 patients (the MCL group) were treated with a 14-gauge intravenous (IV) catheter at least 5.0-cm long at the second intercostal space (ICS), MCL after being placed in the ambulance; and 136 patients (the MAL group) were treated with a 10-gauge IV catheter at least 9.5-cm long at the fifth ICS, MAL on scene. The mean ISS was lower in the MAL cohort (64.5 versus 69.2; P=.007). The mortality rate was 79% in both groups.

 

 

The multivariate model with regard to survival supported that a lower ISS (P<.001) and reported clinical change after NT (P=.003) were significant indicators of survival. No complications from NT were reported.

CONCLUSIONS:

Changing the timing, length of needle, and location of placement did not change mortality in patients requiring NT. Needle thoracostomy was used more frequently after the change in policy, and the MAL cohort was less injured. No increase in reported complications was noted.

la voie axillaire +++

Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy

Laan DV et Al. Injury, Int. J. Care Injured 47 (2016) 797–804

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Une publication, une de plus, qui met en avant l'abord axillaire pour la décompression thoracique et qui insiste sur le peu de preuve de l'inocuité des cathéters de 8 cm. On rappelle que la thoracostomie au doigt reste la référence.

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Introduction:

Current Advanced Trauma Life Support guidelines recommend decompression for thoracic tension physiology using a 5-cm angiocatheter at the second intercostal space (ICS) on the midclavicular line (MCL). High failure rates occur. Through systematic review and meta-analysis, we aimed to determine the chest wall thickness (CWT) of the 2nd ICS-MCL, the 4th/5th ICS at the anterior axillary line (AAL), the 4th/5th ICS mid axillary line (MAL) and needle thoracostomy failure rates using the currently recommended 5-cm angiocatheter.

Methods:

A comprehensive search of several databases from their inception to July 24, 2014 was conducted. The search was limited to the English language, and all study populations were included. Studies were appraised by two independent reviewers according to a priori defined PRISMA inclusion and exclusion criteria. Continuous outcomes (CWT) were evaluated using weighted mean difference and binary outcomes (failure with 5-cm needle) were assessed using incidence rate. Outcomes were pooled using the random-effects model.

Results:

The search resulted in 34,652 studies of which 15 were included for CWT analysis, 13 for NT effectiveness. Mean CWT was 42.79 mm (95% CI, 38.78–46.81) at 2nd ICS-MCL, 39.85 mm (95% CI, 28.70–51.00) at MAL, and 34.33 mm (95% CI, 28.20–40.47) at AAL (P = .08). Mean failure rate was 38% (95% CI, 24–54) at 2nd ICS-MCL, 31% (95% CI, 10–64) at MAL, and 13% (95% CI, 8–22) at AAL (P = .01).

Conclusion:

Evidence from observational studies suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression in multiple populations.

Thoracostomie: ni en antérieur ou postérieur mais par voie latérale

Evaluation of the Risk of Intercostal Artery Laceration During Thoracentesis in Elderly Patients by Using 3D-CT Angiography

Yoneyama H. et Al Inter Med 49: 289-292, 2010

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Les artères intercostales ne cheminent pas toujours au rebord inférieur de de la côte supérieure. Il existe de plus des rameaux latéraux plutôt postérieurs. Donc il faut aborder le thorax par voie latérale. Une approche latérale au niveau des 4/5èmes espaces intercostaux sur la lgne axillaire moyennne est sécuritaire.  

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Objective

Our study was undertaken to determine the location of the tortuous intercostal artery in elderly patients by using 3D-CT angiography in order to prevent laceration during thoracentesis.

Methods

We evaluated the data of 3D-CT angiography of the intercostal artery in consecutive patients who had undergone contrast chest CT scan in our hospital from December 2007 to April 2008. We considered the “percent safe space” (the shortest lower rib-to-intercostal artery distance/the upper rib-to-lower rib distance) to be an index of safety that can be used to prevent laceration of the intercostal artery during thoracentesis. We measured this index at 3 points: the total site (5-10 cm lateral to the spine), the lateral site (9-10 cm lateral to the spine), and the medial site (5-6 cm lateral to the spine).

Results

We evaluated 33 cases (25 males and 8 females; mean age, 74.2 years). The mean percent safe space at the total site was 58.6%. The percent safe space at the total site tended to decrease with advancing age, but the correlation was low (p=0.0378, r=-0.3631). The percent safe space at the lateral site (mean, 79.8%) was significantly higher than that at the medial site (61.2%, p<0.0001).

Conclusion

We showed that the intercostal artery is tortuous and does not always lie along the inferior edge of the rib and that the percent safe space at the lateral site is significantly higher than that at the medial site in elderly patients

Décompression à l'aiguille: Pas fiable

Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax?

Martin M et Al. J Trauma Acute Care Surg. 2012;73: 1412-1417

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La décompression thoracique est une des mesures qui vise à réduire le nombre de morts évitables. Il s'agit d'une procédure mise en oeuvre peu fréquemment. L'exsufflation à l'aiguille est la méthode enseignée. Il existe beaucoup de débats concernant le lieu de ponction (plutôt par voie axillaire et non par voie antérieure), la longueur du cathéter (certains proposent 8 cm au risque de ponction parenchymateuse et des gros vaisseaux), le diamètre. Le travail proposé est très intéressant car il exprime toute les réserves qui doivent encadrer ce geste qui ne semble pas aussi efficace que cela car outre les problèmes mécanique il apparaît bien qu'un cathéter de 14G risque d'être insuffisant. On rappelle quand même que la thoracostomie au doigt est toujours possible et que votre doigt a de fortes chances de mesurer 8 cm donc de pouvoir pénétrer dans un thorax après création d'un stomie intercostale à la pince de monro-kelly.

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BACKGROUND:

Tension pneumothorax (tPTX) is a common and potentially fatal event after thoracic trauma. Needle decompression is the currently accepted first-line intervention but has not been well validated. The purpose of this study was to evaluate the effectiveness of a properly placed and patent needle thoracostomy (NT) compared with standard tube thoracostomy (TT) in a swine model of tPTX.

METHODS:

Six adult swine underwent instrumentation and creation of tPTX using thoracic CO2 insufflation via a balloon trocar. A continued 1 L/min insufflation was maintained to simulate an ongoing air leak. The efficacy and failure rate of NT (14 gauge) compared with TT (34F) was assessed in two separate arms: (1) tPTX with hemodynamic compromise and (2) tPTX until pulseless electrical activity (PEA) obtained. Hemodynamics was assessed at 1 and 5 minutes after each intervention.

RESULTS:

A reliable and highly reproducible tPTX was created in all animals with a mean insufflation volume of 2441 mL. tPTX resulted in the systolic blood pressure declining 54% from baseline (128Y58 mm Hg), cardiac output declining by 77% (7Y1.6 L/min), and equalization of central venous pressure and wedge pressures. In the first arm, there were 19 tPTX events treated with NT placement. All NTs were patent on initial placement, but 5 (26%) demonstrated mechanical failure (due to kinking, obstruction, or dislodgment) within 5 minutes of placement, all associated with hemodynamic decline. Among the 14 NTs that remained patent at 5 minutes, 6 (43%) failed to relieve tension physiology for an overall failure rate of 58%. Decompression with TTwas successful in relieving tPTX in 100%. In the second arm, there were 21 tPTX with PEA events treated initially with either NT (n = 14) or TT (n = 7). The NT failed to restore perfusion in nine events (64%), whereas TT was successful in 100% of events as a primary intervention and restored perfusion as a rescue intervention in eight of the nine NT failures (88%).

CONCLUSION: Thoracic insufflation produced a reliable and easily controlled model of tPTX. NT was associated with high failure rates for relief of tension physiology and for treatment of tPTX-induced PEA and was due to both mechanical failure and inadequate tPTX evacuation. This performance data should be considered in future NT guideline development and equipment design

Exsufflation: Ø plutôt que longueur

Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience

Chen J et Al. Can J Surg 2015;58(3):S118-S124

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Il existe un grand débat sur la nature du cathéter à utiliser pour décomprimer un thorx sous pression. Ce travail est intéressant car, alors qu'il existe une forte pression pour recourir à des cathéters de 8cm, il rapporte une expérience de terrain conséquente où le recours à un angiocath n'a pas été lié à un taux d'échec rédhibitoire puisque 8 fois sur 1 une amélioration clinique est notée. Pour ces auteurs le débat porte plus sur le diamètre du cathéter que sa longueur. Ce document insiste également sur la disparition unilatérale du murmure vésiculaire comme repère du côté à ponctionner.

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Contexte :

La thoracotomie à l’aiguille (TA) pour le pneumothorax sous tension sur les lieux mêmes du traumatisme peut sauver des vies. Des données récentes ont mis en doute l’efficacité des dispositifs de TA classiques. C’est pourquoi le corps médical de l’armée israélienne (CMAI) a récemment proposé un cathéter plus long, plus large et plus résistant pour décomprimer rapidement le pneumothorax. Le présent article résume l’expérience du CMAI en matière de décompression des pneumothorax au moyen de la TA.

Méthodes :

Nous avons passé en revue le registre des traumatismes de l’armée israé- lienne entre janvier 1997 et octobre 2012 pour relever tous les cas où une TA a été tentée.

Résultats :

Durant la période de l’étude 111 patients en tout ont subi une décompression à l’aide d’une TA. La plupart des cas (54 %) résultaient de blessures par balles; les accidents de la route venaient au second rang (16 %). La plupart (79 %) des TA ont été effectuées sur les lieux, tandis que les autres ont été effectuées durant l’évacuation par ambulance ou par hélicoptère (13 % et 4 %, respectivement). L’atténuation des bruits respiratoires du côté affecté était l’une des indications cliniques les plus fréquentes de la TA, enregistrée dans 28 % des cas. L’atténuation des bruits respiratoires était plus fréquente chez les patients qui ont survécu (37 % c. 19 %, p < 0,001). Un drain thoracique a été installé sur le terrain chez 35 patients (32 %), à chaque fois après une TA.

Conclusion :

La TA standard s’accompagne d’un taux d’échec élevé sur le champ de bataille. Une autre mesure de décompression, comme le cathéter Vygon, semble être une solution de rechange envisageable à la TA classique.

Exsuffler: Aiguille de 6,44cm ?

Sufficient catheter length for pneumothorax needle decompression: a meta-analysis

Clemency BM et Al. Prehosp Disaster Med. 2015 Jun;30(3):249-53

Abstract

Introduction Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis.

METHODS:

A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness.

RESULTS:

The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm. Discussion A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence. 

Par le côté et avec du long ?

Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax

Chang SJ et Al. J Trauma Acute Care Surg. 2014;76: 1029-1034

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La décompression d'un thorax sous pression doit maintenant se faire par voie latérale, la voie antérieure étant associée à un taux d'échec important notamment avec l'emploi de cathéters veineux classiques dont la longueur est rarement supérieure à 5 cm. Le recours à des cathéters de 8 cm est ainsi prôné dans la littérature anglo-saxone sur des seuls arguments  anatomiques. Le risque de ponction de structures intrathoraciques est réel et doit rendre mesuré quand au recours à de tels dispositifs. On rappelle que la thoracostomie au doigt doit être considérée comme la référence. 

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BACKGROUND: Five-centimeter needles at the second intercostal space midclavicular line (2MCL) have high failure rates for decompression of tension pneumothorax. This study evaluates 8-cm needles directed at the fourth intercostal space anterior axillary line (4AAL).

 

METHODS: Retrospective radiographic analysis of 100 consecutive trauma patients 18 years or older from January to September 2011. Measurements of chest wall thickness (CWT) and depth to vital structure (DVS) were obtained at 2MCL and 4AAL. 4AAL measurements were taken based on two angles: closest vital structure and perpendicular to the chest wall. Primary outcome measures were radiographic decompression (RD) (defined as CWT G 80 mm) and radiographic noninjury (RNI) (DVS 9

80 mm) of 8-cm needles at 4AAL. Secondary outcome measures are effect of angle of entry on RNI at 4AAL, RD and RNI of 8-cm needles at 2MCL, and comparison of 5-cm needles with 8-cm needles at both locations.

 

RESULTS: Eighty-four percent of the patients were male, with mean Injury Severity Score (ISS) of 17.7 (range, 1.0Y66.0) and body mass index of 26.8 (16.5Y48.4). Mean CWT at 4AAL ranged from 37.6 mm to 39.9 mm, significantly thinner than mean CWT at 2MCL (43.3Y46.7 mm). Eight-centimeter needle RD was more than 96% at both 4AAL and 2MCL. Five-centimeter RD ranged from 66% to 81% at all sites. Mean DVS at 4AAL ranged from 91.8 mm to 128.0 mm. RNI at all sites was more than 91% except at left 4AAL, when taken to the closest vital structure (mean DVS, 91.8 mm), with 68% RNI. Perpendicular entry

increased DVS to 109.4 mm and subsequent RNI to 91%. Five-centimeter RNI at all sites was more than 99%.

 

CONCLUSION: CWT at 4AAL is significantly thinner than 2MCL. Based on radiographic measurements, 8-cm catheters have a higher chance of pleural decompression when compared with 5-cm catheters. Steeper angle of entry at 4AAL improves 8-cm noninjury rates to more than 91%. 

 

 

 

 

 

 

Pneumothorax: Passez par le côté

Failed needle decompression of bilateral spontaneous tension pneumothorax

Bac PT et Al. Acta Anaesthesiol Scand. 2015 Apr 21. doi: 10.1111/aas.12538. [Epub ahead of print]

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Cet article a le mérite de rappeler que la détresse respiratoire est ua prmeier plan enc as de pneumothorax suffocant chez le patient non ventilé, que la voie latérale doit être privilégié et surtout que la thoracostomie simple est parfaitement efficace.

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This case report presents a young male admitted with primary bilateral spontaneous tension pneumothorax and severe respiratory distress. This is an extremely rare condition. The patient was on the verge of hypoxic cardiac arrest and the attempted needle thoracocentesis was unsuccessful. Needle thoracocentesis in the midclavicular line of the second intercostal space is widely used and recommended as first-line treatment of tension pneumothorax. Reviewing the literature, the procedure is not based on solid evidence. It has high failure rates and potentially serious complications. Alternatives to this approach are perhaps more appropriate. Correctly done, needle thoracocentesis has its place in the presence of a diagnosed or suspected tension pneumothorax when no other options are available. If needle thoracocentesis is chosen, then insertion in the mid-anterior axillary line of the 3rd–5th intercostal space is an appropriate alternative site. Otherwise, lateral thoracostomy, with or without chest tube insertion, is a safe procedure with a high success rate. It should be considered as the first-line treatment of tension pneumothorax, particularly in the unstable patient

Pansements 3 côtés: C'est efficace

Vented Chest Seals for Prevention of Tension Pneumothorax in a Communicating Pneumothorax

Kotora JG et Al.  J Emerg Med. 2013 Nov;45(5):686-94.

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La prise en charge d'une plaie thoracique soufflante (1) est une éventualité peu fréquente qui expose d'une part au risque de détresse respiratoire aiguë et d'autre part au risque d'instabilité hémodynamique en rapport avec le caractère compressif d'un épanchement intra-thoracique gazeux ou liquidien (2) L'exsufflation et/ou la pose d'un pansement 3 côtés sont alors requis. Ce dernier peut être réalisé simplement ou par l'emploi de dispositifs commerciaux prêts à l'emploi. Le travail présenté exprime l'efficacité des pansements "3 côtés" de dernières générations aussi bien en matière d'adhérence cutanée que d'efficacité d'évacuation de l'air et secrétions intra-thoraciques. Ils jouent donc ainsi parfaitement le rôle pour lesquels ils ont été conçus (3).

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BACKGROUND:

Tension pneumothorax accounts for 3%–4% of combat casualties and 10% of civilian chest trauma. Air entering a wound via a communicating pneumothorax rather than by the trachea can result in respiratory arrest and death. In such cases, the Committee on Tactical Combat Casualty Care advocates the use of unvented chest seals to prevent respiratory compromise.

OBJECTIVE: A comparison of three commercially available vented chest seals was undertaken to evaluate the efficacy of tension pneumothorax prevention after seal application.

METHODS:

A surgical thoracostomy was created and sealed by placing a shortened 10-mL syringe barrel (with plunger in place) into the wound. Tension pneumothorax was achieved via air introduction through a Cordis to a maximum volume of 50 mL/kg. A 20% drop in mean arterial pressure or a 20% increase in heart rate confirmed hemodynamic compromise. After evacuation, one of three vented chest seals (HyFin ®, n = 8; Sentinel ®, n = 8, SAM ®, n = 8) was applied. Air was injected to a maximum of 50 mL/kg twice, followed by a 10% autologous blood infusion, and finally, a third 50 mL/kg air bolus. Survivors completed all three interventions, and a 15-min recovery period.

 RESULTS:

The introduction of 29.0 (±11.5) mL/kg of air resulted in tension physiology. All three seals effectively evacuated air and blood. Hemodynamic compromise failed to develop with a chest seal in place.

 CONCLUSIONS:

HyFin ®, SAM ®, and Sentinel ® vented chest seals are equally effective in evacuating blood and air in a communicating pneumothorax model. All three prevented tension pneumothorax formation after penetrating thoracic trauma

Exsufflation: 1 / 4 sans pneumothorax !

Inadequate Needle Thoracostomy Rate in the Prehospital Setting for Presumed Pneumothorax. An Ultrasound Study

Blaivas M.  J Ultrasound Med 2010; 29:1285–1289

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Nombreux ont attiré l'attention sur le risque d'inefficacité des exsufflations au cathéter à cause de la longueur de ces derniers, plus court que l'épaisseur de la paroi thoracique. Certains prônent l'emploi de cathéter de plus de 8 cm sans véritablement de fondements scientifiques (Lire cette analyse). Entre des mains peu expérimentées cette pratique apparaît dangereuse du fait du fait des erreurs faites sur les niveaux de ponction, ce d'autant que ces cathéters ne sont pas très efficaces dans le temps. L'article proposé incite encore plus à la nécessaire prudence à avoir avant de faire pénétrer une aiguille dans un thorax. En effet ce geste serait pratiqué 1 fois sur 4 en l'absence de pneumothorax. 

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Objective. The purpose of this study was to evaluate the frequency of inadequate needle chest tho-racostomy in the prehospital setting in trauma patients suspected of having a pneumothorax (PTX) onthe basis of physical examination.

Methods. This study took place at a level I trauma center. All trauma patients arriving via emergency medical services with a suspected PTX and a needle thoracostomy were evaluated for a PTX with bedside ultrasound. Patients too unstable for ultrasound evaluation before tube thoracostomy were excluded, and convenience sampling was used. All patients were scanned while supine. Examinations began at the midclavicular line and included the second through fifth ribs. If no sliding lung sign (SLS) was noted, a PTX was suspected, and the lung point was sought for definitive confirmation. When an SLS was noted throughout and a PTX was ruled out on ultrasound imaging, the thoracostomy catheter was removed. Descriptive statistics were calculated.

Results. A total of 57 patients were evaluated over a 3-year period. All had at least 1 needle thoracostomy attempted; 1 patient underwent 3 attempts. Fifteen patients (26%) had a normal SLS on ultrasound examination and no PTX after the thoracostomy catheter was removed. None of the 15 patients were later discovered to have a PTX on subsequent computed tomography. Conclusions. In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.

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Recourir à l'échographie pleurale et réaliser ce geste par voie latérale avec un cathéter de 5 cm apparaissent être sécuritaire.

Pneumothorax: Pansement NON OCCLUSIF

Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model

Kheirabadi BS et all. J Trauma Acute Care Surg. 2013;75: 150-156

La procédure du sauvetage au combat indique qu'un thorax ouvert ne doit JAMAIS être fermé et qu'un pansement 3 côtés doit être mis en place  pour éviter toute surpression intrathoracique. Ceci diffère du TCCC américain qui recommande l'occlusion de la plaie et la surveillance du blessé à la recherche d'un pneumothorax suffocant. Mais les choses évoluent à la lumière de la remise en question de pratiques pas toujours bien documentées. Le TCCC va proposer le recours non pas à l'emploi d'un pansement 3 côtés consommateur de temps mais à l'utilisation de pansements adhésifs prêts à l'emploi.

L'article présenté montre très clairement l'intérêt de la mise en place de pansement permettant l'évacuation de l'air intrathoracique.

Au delà de l'intérêt des dispositifs prêts à l'emploi avec valve de surpression, il y a le problème du choix du modèle. La procédure du sauvetage au combat propose la valve d'asherman, qui doit être considérée comme obsolète car bien qu'efficace, sa capacité d'adhésion à la peau est perfectible. Il semble que les modèles concurrents (Hyfin Vent Chest Seal, SAM chest seal et Sentinel chest seal) proposés par l'industrie aient la même efficacité

Epaisseur de paroi thoracique: Le point chez le militaire français

Mesure de l’épaisseur de la paroi thoracique chez des militaires français :

Quelle technique pour l’exsufflation du pneumothorax compressif lors du sauvetage au combat?

A propos d’une étude descriptive réalisée du 1er Mars au 15 Avril 2010

au 7ème Bataillon de Chasseurs Alpins de Bourg Saint Maurice.

LAMBLIN A. Thèse Lyon 2012

 

Le diaporama de présentation      :       EpThoDiaporama.pdf

La thèse                                          :       Lien

Exsufflation à l'aiguille: Le risque est rare mais réel !

Subclavian artery laceration: A serious complication of needle decompression

Riwoe D et all. Emergency Medicine Australasia (2011) 23, 651–653

Un article qui rapporte la survenue d'une dialcération de l'artère sous clavière après exsufflation à l'aiguille par voie antérieure. Les auteurs militent pour la réalisation d'une thoracostomie au doigt par voie latérale ou après repérage échographique sinon l'emploi de repère cutanés préconisés par Wax et coll. qui font appel à la reconnaissance de la fourchette sternale et la ligne médio-thoracique mamelonnaire.

Passer par le côté, c'est mieux

J Trauma. 2011 Nov;71(5):1099-103; discussion 1103.

Optimal positioning for emergent needle thoracostomy: a cadaver-based study.

Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D.

Source

Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California 90033-4525, USA. [e-mail]

Abstract

BACKGROUND:

Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate.

METHODS:

Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position.

RESULTS:

A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008).

CONCLUSIONS:

In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

Exsufflation: 5 cm suffisent VRAIMENT !

Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan
Injury, In Press, Corrected Proof, Available online 24 December 2010
Takeshi Yamagiwa, Seiji Morita, Rie Yamamoto, Tomoko Seki, Katsuhiko Sugimoto, Sadaki Inokuchi

PDF (164 K) 

Background

Previous studies reported a high failure rate in relieving tension pneumothorax by needle thoracostomy, because the catheter was not sufficiently long to access the pleural space. The Advanced Trauma Life Support guideline recommends needle thoracostomy at the second intercostal space in the middle clavicular line using a 5.0-cm catheter, whereas the corresponding guideline in Japan does not mention a catheter length. It is necessary to measure the chest wall thickness (CWT) and determine the appropriate catheter length taking the differences of habitus in race and region into consideration. This study was designed to analyse CWT in Japanese trauma patients by computed tomography and to determine the percentage of patients whose pleural space would be accessible using a 5.0-cm catheter.

Patients and methods

We performed a retrospective review of chest computed tomography of 256 adult Japanese trauma patients who were admitted to the level 1 trauma centre of Tokai University Hospital in Kanagawa, Japan between January and July 2008. In 256 patients, the CWT at 512 sites (left and right sides) was measured by chest computed tomography at the second intercostal space in the middle clavicular line. The frequency of measurement sites <5.0 cm was calculated simultaneously.

The samples were divided according to gender, side (left and right), abbreviated injury scale (<3, ≧3), arm position during examination (up/down), and the existence or non-existence of associated injuries (pneumothorax, subcutaneous emphysema, and fracture of the sternum and ribs); the CWT of each group was compared.

Results

The mean CWT measured in 192 males and 64 females was 3.06 ± 1.02 cm. The CWT values at 483 sites (94.3%) were less than 5.0 cm. The CWT of females was significantly greater than that of males (3.66 cm vs. 2.85 cm, p < 0.0001), and patients with subcutaneous emphysema had greater CWTs than those without it (4.16 cm vs. 3.01 cm, p < 0.0001).

Conclusion

The mean CWT at the second intercostal space in the middle clavicular line was 3.06 cm. It is likely that over 94% of Japanese trauma patients could be treated with a 5.0-cm catheter.