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The Case For Needle Decompression

Perhaps no component of the TCCC guidelines has been more controversial for the medical establishment than the idea of needle thoracentesis or needle decompression (ND) by non-medical personnel.  Long held as an advanced procedure reserved for physicians and paramedics, the introduction of this invasive skill to combat lifesavers caused a stir that has yet to die down in some sectors.

Tension Pneumothorax

ND is the current best-practice for minimally invasive treatment of tension pneumothorax.  Caused by either blunt or penetrating trauma (along with medical causes that are outside the scope of this discussion), tension pneumothorax is the compression of the lung(s) and other thoracic structures by trapped air inside the chest cavity.  Considered rare in the non-emergency setting, recent battlefield data has proven that it can be quite common in regards to causes of fatalities.  In fact, the data cited by the military indicates that pneumothorax is the second leading cause of battlefield deaths, making up 33% of all combat related fatalities.  Extrapolating this to cases of law enforcement fatalities, over a 10 year span, somewhere between 11 and 29 of the 90 police officers who died as a result of chest trauma may have experienced tension pneumothorax, representing between 12 and 32% of these cases.  Additionally, 37.8% of all LEO fatalities experienced some sort of chest trauma and it is wholly possible that tension pneumothorax constituted a larger portion of this (Sztajnkrycer, 2010).

Needle Decompression (ND)

So what is needle decompression?  Needle decompression is the placement of a large gauge needle, typically in the form of an over-the-needle-catheter (OTNC) into the chest cavity in order to allow the escape of air from that cavity and subsequent re-inflation of the lung.  There are two commonly accepted anatomic spots for this, one on the front of the chest, and the other below the arm pit.  Until recently, this was a procedure reserved for physicians and field paramedics, though in the last 10 years after a roll-out by the military to non-medical personnel, it has become increasingly more common in “tactical first aid” and similar courses.  ND is still considered the best treatment for tension pneumothorax outside of a surgical thoracostomy which is, and will likely remain, well within the sacred realm of the physician.

Risks

So we know what tension pneumothorax is, we know that it’s killing people, and the treatment seems simple enough, why aren’t all of us carrying big needles in our first aid kits??  Well a couple reasons.  First of all, there are definite and specific risks that come with ND.  Not least among these is the idea that if there is not already a pneumothorax, one can certainly be introduced by the unnecessary placement of an OTNC.  Second is the risk of infection.  Often the idea of infection gets a bit of a blow-off as something “we can treat later”.  While we shouldn’t let concerns of infection stand in the way of appropriate, life saving treatment, it is worth considering before we needlessly breach the body’s best defense against infection and drag everything from our world of icky into the patient’s chest cavity.  Third is the risk of inappropriate placement resulting in new injuries that could include life-threatening hemorrhage, and cardiac tamponade(Leigh-Smith & Harris, 2005).  This can certainly be overcome with training, but it must be recognized that this is a skill that requires more than a PowerPoint before being employed in the field. This is especially true for those in law enforcement who will be expected to perform under high-stress, tactical conditions.

Indications

Here’s where the controversy really begins.  Under initial training, it was thought that any time a soldier experienced a chest injury; the combat lifesaver should place a needle early and often to treat tension pneumothorax.  The evidence since then has not necessarily held this up as the best practice.  Early schools of thought indicated that respiratory distress alone was enough of an indication to start sticking your partner with reckless abandon.   While many of the early indications of pneumothorax have a high degree of sensitivity (they’re often associated with tension pneumothorax), few of them have a high degree of specificity (where they’re only associated with tension pneumothorax). These include chest pain, air hunger and respiratory distress, fast breathing, fast heart rate, and agitation. To make matters even more difficult, waiting for the “classic” signs of a tension pneumothorax (decreased breath sounds, low blood pressure, falling pulse oximetry, and a decreasing level of consciousness) often means that you’ve found yourself in the “pre-terminal” phase of care (Leigh-Smith & Harris, 2005).  Not to mention that many of these assessments are outside of the scope of training for most police officers and likely outside the realm of possibility in the tactical environment.  So in the out-of-hospital setting, it can often be an educated guess at best and crapshoot at worst. 

Training

The last question in this debate is whether or not somebody with no medical background can be trained to perform a comparatively advanced procedure in a short period of time, retain that knowledge for a period of time and then perform it under stress.  While I’m sure many people have anecdotal evidence one way or another, we don’t really like anecdotes, so we went to the research.  On the first two questions, the answer is a resounding yes. (Sztajnkrycer, 2008).  22 non-medical law enforcement personnel were provided a 90 minute in-service training session on needle thoracentesis with a test to follow.  Not only did immediate test scores show a solid understanding of the knowledge, but tests conducted one and six months later held that the information was retained.  Now the question that remains, is whether or not these results could be effectively placed into use in the field to correctly perform ND, and it is here that things get a bit murkier.  One Canadian study discovered that not only was typical chest wall thickness of military members significant enough to make standard ND ineffective 75% of the time, but they also found an alarmingly high rate of inappropriate placement, resulting in the potential for injuries to the heart or great vessels (Savage, Forestier, Withers, Tien, & Pannell, 2011).

Conclusion

So what does that mean for us?  Should we all be packing needles in our trauma kits?  The answer is a solid “it depends”.  It depends on your department’s commitment to training.  It depends on your commitment to training.  And it depends on your fiscal resources to provide not only the equipment but the training to go with it, both up front and each year to ensure you remain proficient.  We’re certainly not advocating that every person who experiences chest trauma get a chest dart carte blanche.  We do, however, think that it’s an important tool that, when used in the right circumstances, can and will save lives.

 

 


Works Cited

Leigh-Smith, S., & Harris, T. (2005). Tension Pneumothorax - Time for a re-think? Emergency Medicine Journal , 8-16.

Savage, E., Forestier, C., Withers, N., Tien, H., & Pannell, D. (2011). Tactical Combat Casualty Care in the Canadian Forces: lessons learned from the Afghan war. Canadian Journal of Surgery , 118-123.

Sztajnkrycer, M. D. (2008). Needle Thoracostomy by Non-Medical Law Enforcement Personnel. Prehospital and Disaster Medicine , 553-557.

Sztajnkrycer, M. D. (2010). Learning from tragedy: Preventing officer deaths with medical interventions.  Tactical edge, 54-58.

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