Prehospital Trauma Compendium: Traumatic Pneumothorax Care: Position Statement and Resource Document of NAEMSP

Emergency medical services (EMS) clinicians manage patients with traumatic pneumothoraxes. These may be simple pneumothoraxes that are less clinically impactful, or tension pneumothoraxes that disturb perfusion, lead to shock, and impart significant risk for morbidity and mortality. Needle thoracostomy is the most common EMS treatment of tension pneumothorax, but despite the potentially life-saving value of needle thoracostomy, reports indicate frequent misapplication of the procedure as well as low rates of successful decompression. This has led some to question the value of prehospital needle thoracostomy and has prompted consideration of alternative approaches to management (e.g., simple thoracostomy, tube thoracostomy). EMS clinicians must determine when pleural decompression is indicated and optimize the safety and effectiveness of the procedure. Furthermore, there is also ambiguity regarding EMS management of open pneumothoraxes. To provide evidence-based guidance on the management of traumatic pneumothoraxes in the EMS setting, the National Association of EMS Physicians (NAEMSP) performed a structured literature review and developed the following recommendations supported by the evidence summarized in the accompanying resource document. EMS identification of a tension pneumothorax must be guided by a combination of risk factors and physical findings, which may be augmented by diagnostic technologies. EMS clinicians should recognize the differences in the clinical presentation of a tension pneumothorax in spontaneously breathing patients and in patients receiving positive pressure ventilation (PPV). EMS clinicians should not perform pleural decompression in patients with simple pneumothoraxes but should perform pleural decompression in patients with tension pneumothorax, if within the clinician’s scope of practice. When within scope of practice, EMS clinicians should use needle thoracostomy as the primary strategy for pleural decompression of tension pneumothorax in most cases. EMS clinicians should take a patient-individualized approach to performing needle thoracostomy, influenced by factors known to impact chest wall thickness and risk for iatrogenic injury. Simple thoracostomy and tube thoracostomy may be used by highly trained EMS clinicians in select clinical settings with appropriate medical oversight and quality assurance. EMS systems must investigate and adopt strategies to confirm successful pleural decompression at the time thoracostomy is