title: Improvement in the prehospital recognition of tension pneumothorax: the effect of a change to paramedic guidelines and education.
abstract: BACKGROUND
  An audit of ambulance service clinical records from 2001 to 2002 in Melbourne, Australia revealed 10 patients with tension pneumothorax on arrival at hospital which had been undetected or untreated by paramedics. The clinical practice guideline for paramedic recognition of tension pneumothorax was subsequently changed to emphasise heightened clinical suspicion of a tension pneumothorax in the setting of chest trauma, especially when patients were managed with positive pressure ventilation. This study was undertaken to determine whether the number of undetected or untreated tension pneumothoraces had decreased after the new clinical practice guideline and associated education program; if there were unintended consequences arising from earlier paramedic intervention; and what effect, if any, this change had on subsequent hospital treatment.
  
  
  METHODS
  Retrospective case note review of all patients requiring intercostal catheter (ICC) insertion at The Alfred Hospital, Melbourne, Australia, using records from Ambulance Victoria, the Alfred Trauma Registry and the National Coronial Information System.
  
  
  RESULTS
  In 2001-2002 paramedics treated 22 patients with suspected tension pneumothorax before transport to the Alfred Hospital. In 2006-2007 this number had increased to 81. There was a decrease from ten to four in the number of unrecognised or untreated tension pneumothoraces between the two time periods. No unintended or adverse consequences of prehospital needle decompression could be found. However, there was an increase in the number of patients who had prehospital needle decompression that needed further treatment for tension pneumothorax on arrival at hospital. This need for further treatment was associated with use of shorter cannulas and unilateral needle decompression by paramedics.
  
  
  CONCLUSIONS
  A small change in clinical practice guidelines, supported by an education and audit program, led to a reduction in unrecognised untreated tension pneumothoraces by paramedics without an increase in complications. Paramedics should be aware that a shorter cannula may fail to reach the pleural space and that both sides of the chest may require decompression.
authors.affiliation: Ambulance Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Australia; Burnet Institute, Australia. Electronic address: kate.cantwell@ambulance.vic.gov.au.
authors.forename: Kate
authors.initials: K
authors.lastname: Cantwell
authors.forename: Stephen
authors.initials: S
authors.lastname: Burgess
authors.forename: Ian
authors.initials: I
authors.lastname: Patrick
authors.forename: Louise
authors.initials: L
authors.lastname: Niggemeyer
authors.forename: Mark
authors.initials: M
authors.lastname: Fitzgerald
authors.forename: Peter
authors.initials: P
authors.lastname: Cameron
authors.forename: Colin
authors.initials: C
authors.lastname: Jones
authors.forename: Diane
authors.initials: D
authors.lastname: Pascoe
mesh_terms: D000488:Allied Health Personnel / Q000193:education*; D000552:Ambulances; D001315:Australia / Q000453:epidemiology; D057785:Catheters / Q000706:statistics & numerical data; D002983:Clinical Competence; D019299:Decompression, Surgical; D004632:Emergency Medical Services / Q000379:methods / Q000592:standards; D006801:Humans; D015601:Injury Severity Score; D009339:Needles / Q000706:statistics & numerical data; D011030:Pneumothorax / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012272:Ribs; D013898:Thoracic Injuries / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D013907:Thoracostomy / Q000009:adverse effects / Q000379:methods*; D014739:Victoria / Q000453:epidemiology
keywords: Chest injury; Clinical practice guideline; Emergency medical services; Intensive care paramedic; Intercostal catheter; Pneumothorax; Prehospital; Tension pneumothorax