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

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.

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