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management
clinical skills
cardiac arrest

Sticking the knife in: Time to review management of tension pneumothorax

04 March 2013
Features
02 March 2013
Volume 5 · Issue 3

Abstract

Outcomes from traumatic cardiac arrest are poor (Lockey et al. 2006; Soar et al, 2010). Those who do survive tend to have had a quickly reversible cuase for their arrest (Vanden Hoek et al, 2010).

One such mechanism is tension pneumothorax; and in a retrospective database review of London HEMS traumatic arrests six patients regained cardiac output immediately following decompression of a tension pneumothorax (Lockey et al. 2006).

Had their tension pneumothoraces not been rapidly decompressed successfully prior to transport to hospital, the continuation of positive pressure ventilation during CPR would likely have further increased intrathoracic pressure. This would render chest compressions ineffective and almost certainly lead to death.

There is currently much doubt surrounding the effectiveness of needle decompression for tension pneumothoraces, and needle decompression without release of air certainly does not rule out this important reversible cause of cardiac arrest (Rojas et al. 1983). In order to improve the outcomes for patients in traumatic cardiac arrest in the UK there is an argument for introducing finger thoracostomy to a paramedics skill set as a safe and effective method of both draining and ruling out tension pneumothorax in the limited setting of traumatic cardiac arrest.

Traumatic cardiac arrests have generally poor outcomes. A retrospective database search of 909 traumatic arrests treated by a physician led, established, inner city helicopter emergency medical service (HEMS) service showed a 7.5 % survival rate for this patient group (Lockey et al. 2006). This could be considered a ‘best case’ survival rate where patients received early, high level care and the majority of reversible causes were identified and if feasible treated.

The main correctable causes are hypoxia, hypovolaemia, cardiac tamponade, hypothermia and tension pneumothorax (Kloeck, 1995). The pathophysiology of these causes make closed chest compressions at best minimally effective if performed prior to their reversal (Vanden Hoek et al, 2010). Other patients have medical causes of cardiac arrest in traumatic settings, this should be suspected in a patient whose clinical condition does not correlate with the injury they have sustained, and treated as such (Hopson et al, 2003).

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Cardiac Arrest
Decompression
Pneumothorax
Thoracostomy
Thoracocentesis