Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults.

INTRODUCTION: We sought to compare the complication rates of prehospital 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 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 complications and length of scene time by decompression technique. RESULTS: Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85). CONCLUSIONS: There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

Neurogenic pulmonary edema.

AIM: We report a case of neurogenic pulmonary edema in a patient who sustained a severe traumatic brain injury in a motorbike accident and review the current literature with regards to the management of neurogenic pulmonary edema (NPE). METHODS: A 17 year old male was involved in a motorbike collision into a tree. Copious amounts of pink frothy sputum was noted on scene. Rapid sequence intubation was performed on scene and video laryngoscopy demonstrated profuse frothy secretions welling up from the larynx. RESULTS: The patient underwent emergency external ventricular drain insertion for intracranial pressure (ICP) monitoring. Intracranial pressures remained refractorily high and a decompressive bifrontal craniectomy was performed on the subsequent day. He was tracheostomised on admission day 24 and discharged from ICU on day 34. DISCUSSION: Neurogenic pulmonary edema is defined as acute respiratory distress triggered by severe sympathetic discharge from acute compromise in the central nervous system. Rapid intervention with intubation is often necessary to protect the airways and facilitate diagnostic evaluation. Reduction of ICP and supportive mechanical ventilation to improve oxygenation is necessary. Positive end-expiratory pressure should be carefully applied to balance recruitment of alveoli and minimisation of ICP. Although NPE is estimated to resolve within 72 h in more than half of patients, prognosis is generally poor due to the severity of the underlying brain injury, with estimated mortality rates of between 60 and 100%. CONCLUSION: Neurogenic pulmonary edema is a potentially life-threatening complication of severe brain injury and should be recognised early to facilitate management.