Research

JAMA Surgery | Original Investigation

Association of Prehospital Needle Decompression With Mortality

Among Injured Patients Requiring Emergency Chest Decompression
Daniel Muchnok, NRP; Allison Vargo, BS; Andrew-Paul Deeb, MD, MSc; Francis X. Guyette, MD, MPH; Joshua B. Brown, MD, MSc

Invited Commentary
IMPORTANCE Prehospital needle decompression (PHND) is a rare but potentially life-saving Supplemental content
procedure. Prior studies on chest decompression in trauma patients have been small, limited
to single institutions or emergency medical services (EMS) agencies, and lacked appropriate
comparator groups, making the effectiveness of this intervention uncertain.

OBJECTIVE To determine the association of PHND with early mortality in patients requiring
emergent chest decompression.

DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort study conducted from
January 1, 2000, to March 18, 2020, using the Pennsylvania Trauma Outcomes Study
database. Patients older than 15 years who were transported from the scene of injury were
included in the analysis. Data were analyzed between April 28, 2021, and September 18, 2021.

EXPOSURES Patients without PHND but undergoing tube thoracostomy within 15 minutes of
arrival at the trauma center were the comparison group that may have benefited from PHND.

MAIN OUTCOMES AND MEASURES Mixed-effect logistic regression was used to determine the
variability in PHND between patient and EMS agency factors, as well as the association
between risk-adjusted 24-hour mortality and PHND, accounting for clustering by center and
year. Propensity score matching, instrumental variable analysis using EMS agency-level PHND
proportion, and several sensitivity analyses were performed to address potential bias.

RESULTS A total of 8469 patients were included in this study; 1337 patients (11%) had PHND
(median [IQR] age, 37 [25-52] years; 1096 male patients [82.0%]), and 7132 patients (84.2%)
had emergent tube thoracostomy (median [IQR] age, 32 [23-48] years; 6083 male patients
[85.3%]). PHND rates were stable over the study period between 0.2% and 0.5%. Patient
factors accounted for 43% of the variation in PHND rates, whereas EMS agency accounted
for 57% of the variation. PHND was associated with a 25% decrease in odds of 24-hour
mortality (odds ratio [OR], 0.75; 95% CI, 0.61-0.94; P = .01). Similar results were found in
patients who survived their ED stay (OR, 0.68; 95% CI, 0.52-0.89; P < .01), excluding severe
traumatic brain injury (OR, 0.65; 95% CI, 0.45-0.95; P = .03), and restricted to patients with
severe chest injury (OR, 0.72; 95% CI, 0.55-0.93; P = .01). PHND was also associated with
lower odds of 24-hour mortality after propensity matching (OR, 0.79; 95% CI, 0.62-0.98;
P = .04) when restricting matches to the same EMS agency (OR, 0.74; 95% CI, 0.56-0.99;
P = .04) and in instrumental variable probit regression (coefficient, −0.60; 95% CI, –1.04 to
–0.16; P < .01).

CONCLUSIONS AND RELEVANCE In this cohort study, PHND was associated with lower 24-hour
mortality compared with emergent trauma center chest tube placement in trauma patients.
Although performed rarely, PHND can be a life-saving intervention and should be reinforced
in EMS education for appropriately selected trauma patients. Author Affiliations: Division of
General/Trauma Surgery, Department
of Surgery, University of Pittsburgh
Medical Center, Pittsburgh,
Pennsylvania (Muchnok, Vargo, Deeb,
Brown); Department of Emergency
Medicine, University of Pittsburgh
Medical Center, Pittsburgh,
Pennsylvania (Guyette).
Corresponding Author: Joshua B.
Brown, MD, MSc, Division of General/
Trauma Surgery, Department of
Surgery, University of Pittsburgh
Medical Center, PUH F1266.2, 200
JAMA Surg. doi:10.1001/jamasurg.2022.3552 Lothrop St, Pittsburgh, PA 15213
Published online August 17, 2022. (brownjb@upmc.edu).

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 Research Original Investigation Prehospital Needle Decompression and Mortality in Patients Requiring Chest Decompression
T
rauma is a leading cause of death in the US,1 with chest
trauma contributing to mortality in up to 60% of
cases.2 Prehospital needle decompression (PHND) is a
life-saving intervention to temporarily treat tension pneu-
mothorax by emergency medical services (EMS) clinicians.
Both Advanced Trauma Life Support and Prehospital
Trauma Life Support courses advocate use of needle de-
compression for the emergent management of tension
pneumothorax.3,4
The effectiveness of PHND is debated, with concerns raised
about appropriate patient selection and procedural
technique.5-7 Prehospital needle decompression is rare; exist-
ing literature on the procedure consists of small, descriptive
studies over short time periods.8,9 They typically include a
single EMS agency or destination facility, thereby limiting
generalizability.8-10 PHND is performed empirically based on
clinical findings in the field. Tension pneumothorax cannot be
confirmed after PHND is performed, making retrospective re-
view challenging. Most prior work lacks a comparator group
to evaluate outcomes between those who did or did not un-
dergo PHND.
This is important as several studies question the benefits
of prehospital procedures, some even suggesting harm, par-
ticularly in the urban penetrating population supporting a
“scoop-and-run” approach.11,12 However, it remains unclear
whether these procedures were indicated in comparator groups
and may simply be markers of more severe injury.
These limitations underscore the need for robust evalua-
tion of PHND and assessment of its potential effect on out-
comes. Our objective was to determine the association of PHND
with early mortality among injured patients requiring emer-
gent chest decompression. We hypothesized that PHND would
be associated with a lower risk of 24-hour mortality com-
pared with emergent tube thoracostomy placement at the
trauma center.
Methods
Study Population
This study was approved by the institutional review board of
the University of Pittsburgh. Between January 1, 2000, and
March 18, 2020, we performed a retrospective cohort analy-
sis of the Pennsylvania Trauma Outcome Study (PTOS) data-
base, a state-wide trauma registry from 44 trauma centers. Data
submission is mandatory for trauma center accreditation in the
state of Pennsylvania. Patients were eligible for inclusion if they
were 16 years or older and transported from the scene. Pa-
tients were excluded if burn was the primary mechanism of
injury, or they were dead on arrival. Patient race and ethnic-
ity data were not specifically gathered for this study owing to
high rates of missingness in the PTOS data set and were not
planned as analysis variables. This study was determined to
be exempt from the need for informed consent by the Univer-
sity of Pittsburgh institutional review board, owing to the use
of deidentified patient data. The Strengthening the Report-
ing of Observational Studies in Epidemiology (STROBE)
reporting guidelines were followed.
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Key Points
Question Is prehospital needle decompression (PHND)
associated with lower 24-hour mortality among trauma patients
requiring emergent chest decompression?
Findings In this cohort analysis of 8469 trauma patients, PHND was
associated with a statistically significant 25% decrease in the odds of
24-hour mortality when compared with tube thoracostomy
placement within 15 minutes of arrival at the trauma center.
Meaning PHND was associated with lower 24-hour mortality
among trauma patients requiring emergent chest decompression
and should be emphasized in appropriately selected patients.
Treatment and Control Groups
Our treatment group was defined as patients undergoing PHND.
This was identified by International Classification of Diseases,
Ninth Revision (ICD-9) and Tenth Revision (ICD-10) procedure
codes (eMethods in the Supplement) plus a location code in-
dication the prehospital setting.
We defined our control group as patients not undergoing
PHND but treated with tube thoracostomy placement within
15 minutes of arrival at the trauma center. As we cannot verify
tension pneumothorax diagnosis in the field, we believe this
represents a group of patients who may have benefited from
PHND given the emergent need for tube thoracostomy after
arrival at the trauma center. Tube thoracostomy was simi-
larly identified using ICD-9 and ICD-10 procedure codes
(eMethods in the Supplement), with the procedure time stamp
and trauma center admission time stamp to calculate the place-
ment time frame.
Missing Data
To address missing data, multiple imputation was performed
for prehospital and admission vital signs, including systolic
blood pressure (SBP), heart rate, respiratory rate (RR), and Glas-
gow Coma Scale (GCS), as well as emergency department (ED)
transfusion requirement. Missing data for patients ranged from
6.5% (555 of 8469) for ED transfusion requirement to 34.0%
(2876 of 8469) for prehospital SBP. Multiple imputation using
iterative, fully conditional specification chained equations was
performed to add 5 imputed data sets.13 Outcome models were
performed using estimation techniques that combine model
coefficients and SEs from each imputed data set while adjust-
ing for the variability between imputed data sets.14 A com-
plete case analysis demonstrated similar results, and thus, the
results of the imputed data set are presented.
Statistical Analysis
We calculated the proportion of eligible trauma patients un-
dergoing PHND on an annual basis over the study period. We
then evaluated the proportion of variation in PHND attribut-
able to patient vs EMS agency factors using 2 mixed-effects lo-
gistic regression models. First, we constructed a model using
PHND as the outcome and no covariates with a random effect
for EMS agency. Next, we fit a similar model adjusting for pre-
hospital time, SBP, heart rate, RR, GCS, intubation, mecha-
nism of injury, and EMS clinician level of care (advanced life
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 Prehospital Needle Decompression and Mortality in Patients Requiring Chest Decompression
Figure 1. Annual Rate of Prehospital Needle Decompression Over the Study Period
50
45
Prehospital needle decompression, %
40
35
30
25
20
15
10
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Year
support [ALS] vs basic life support [BLS]) with a random ef-
fect for EMS agency. We then determined the relative de-
crease in the variance component of the EMS agency by in-
cluding patient-level covariates to estimate what proportion
of variation in PHND was associated with patient factors.
Our primary outcome was 24-hour mortality. For our pri-
mary analysis, we performed mixed-effects logistic regres-
sion to determine the association between 24-hour mortality
and PHND while adjusting for demographics, mechanism, in-
jury severity score, prehospital time, prehospital and admis-
sion vital signs, prehospital and ED blood transfusion, pre-
hospital level of care (ALS vs BLS), transport mode (helicopter
vs ground ambulance), emergent surgery for hemorrhage con-
trol, emergent craniotomy, and severe head, abdomen, or chest
injury defined as an abbreviated injury scale (AIS) score of 3
or more in the respective body region. A 2-level nested ran-
dom effect was included to account for clustering of patients
within trauma centers, as well as within year of admission given
the long study period.
Documented pneumothorax or hemothorax was cap-
tured using ICD-9 and ICD-10 diagnosis codes. We assessed the
association of PHND with patient physiology as a proxy for po-
tential benefit by evaluating the proportion of patients receiv-
ing PHND with resolution of abnormal SBP, heart rate, and/or
RR on trauma center arrival. Continuous data are presented
as median (IQR). Continuous variables were compared using
Wilcoxon rank sum tests, and categorical variables were com-
pared using χ2 tests. Adjusted odds ratios (aORs) with 95% CIs
are reported from regression models. A 2-sided P value ≤ .05
was considered significant. Data analysis was conducted using
Stata, version 17MP (StataCorp). Data were analyzed between
April 28, 2021, and September 18, 2021.
Causal Inference Approaches
To address potential bias for PHND, we used 2 causal infer-
ence approaches. We performed propensity score matching
using the entire study cohort and a separate analysis restrict-
ing matches to patients treated by the same EMS agency. Sec-
ond, we performed an instrumental variable analysis using the
EMS agency-level proportion of PHND. Details of these ap-
proaches are in the eMethods in the Supplement.
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Original Investigation Research
The solid line represents the overall
study rate, and shading represents
the 95% CI.
Sensitivity Analyses
To ensure the robustness of our results, we performed sev-
eral sensitivity analyses. We excluded patients who died in
the ED to exclude patients presenting in extremis, periar-
rest, or cardiac arrest who may have received bilateral rapid
tube thoracostomy empirically and resulted in an increased
mortality rate in the control group. We also excluded
patients with severe head injury (AIS ≥ 3) to exclude early
death from traumatic brain injury in patients who would
not have benefited from PHND. We restricted patients to
those with severe chest injury (AIS ≥ 3) to exclude patients
who may have undergone PHND or tube thoracostomy
empirically but did not actually need the procedure for a
thoracic injury. Similarly, we restricted patients to those
with documented pneumothorax to exclude patients who
may not have benefited from PHND. We also evaluated the
cohort including patients who were DOA to ensure that ex-
clusion did not bias our results with more deaths in the PHND
group. We stratified our evaluation by transport mode to in-
vestigate the association of differences in resources, training,
and experience between EMS clinicians in ground and heli-
copter transport.
Finally, to evaluate the design thresholds that we
selected, we performed our primary analysis using 2-hour,
4-hour, and 6-hour mortality to corroborate the association of
PHND with a spectrum of early mortality. We also compared
patients undergoing PHND to those undergoing ED tube tho-
racostomy at more than 15 minutes from arrival at the trauma
center to ensure appropriateness of the 15-minute threshold
to define emergent tube thoracostomy.
Results
A total of 434 253 eligible trauma patients were identified. The
rate of PHND among all eligible trauma patients was less than
1% annually and stable over the study period (Figure 1). In the
total eligible study population, patient factors accounted for
43% of variation in PHND rates, whereas EMS agency ac-
counted for 57% of PHND variation. PHND rates were stable
over the study period between 0.2% and 0.5%.
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 Research Original Investigation Prehospital Needle Decompression and Mortality in Patients Requiring Chest Decompression

A total of 8469 patients were included in this study; 1337

Table 1. Characteristics of Treatment Groups
patients (11%) had PHND (median [IQR] age, 37 [25-52] years;
1096 male patients [82.0%]; 241 female patients [18.0%]), and Prehospital
Emergent tube needle
7132 patients (84.2%) had emergent tube thoracostomy (me- Characteristic thoracostomy decompression
dian [IQR] age, 32 [23-48] years; 6083 male patients [85.3%]; No. 7132 1337
1048 female patients [14.7%]). The majority of patients with Age, median (IQR), y 32 (23-48) 37 (25-52)
PHND (789 of 1337 [59.0%]) had pneumothorax diagnosed by Sex, No. (%)

ICD-9 or ICD-10 coding compared with half the patients re- Female 1048 (14.7) 241 (18.0)
Male 6083 (85.3) 1096 (82.0)
ceiving tube thoracostomy (3464 of 7132 [48.6%]), whereas
Mechanism, No. (%)
only 15.4% of patients who had PHND (206 of 1337) and 24.9%
Blunt 3272 (45.9) 956 (71.5)
of patients (1175 of 7132) who received tube thoracostomy were
Penetrating 3856 (54.1) 381 (28.5)
diagnosed with hemothorax only (Table 1). Ultimately, 90.9%
ISS, median (IQR) 25 (14-35) 26 (14-38)
of patients with PHND (1215 of 1337) received tube thoracos-
Prehospital
tomy. In the PHND and tube thoracostomy cohorts, patient fac-
Total time, median (IQR), min 33 (23-50) 46 (31-61)
tors accounted for only 12% of variation in PHND rates, whereas
Response time, median (IQR), min 7 (4-13) 9 (4-15)
EMS agency accounted for 88% of PHND variation. Scene time, median (IQR), min 13 (9-20) 17 (11-26)
Patients receiving PHND had resolution of hypotension in Transport time, median (IQR), min 13 (9-20) 15 (11-22)
37.9% (129 of 340), abnormal respiratory rate in 20.8% (89 of SBP, median (IQR), mm Hg 102 (75-128) 110 (80-137)
428), and abnormal heart rate in 16.8% (121 of 720). Overall, Hypotension, No. (%)a 2212 (30.9) 354 (32.6)
32.3% of patients (301 of 931) who received PHND had reso- Heart rate, median (IQR), 94 (66-117) 99 (72-120)
lution of at least 1 of the previously mentioned physiologic beats/min
Tachycardia, No. (%)b 3507 (44.0) 579 (46.1)
abnormalities baon arrival to the trauma center.
RR, median (IQR), 16 (6-23) 16 (4-24)
Regression analysis demonstrated that PHND was associ- respirations/min
ated with a 25% decrease in odds of 24-hour mortality after risk Abnormal RR, No. (%)c 2858 (38.0) 582 (52.8)
adjustment (odds ratio [OR], 0.75; 95% CI, 0.61-0.94; P = .01) GCS score, median (IQR) 8 (3-15) 3 (3-15)
(Table 2), with a risk-adjusted mortality of 28.1% vs 37.8% in pa- Intubation, No. (%) 1285 (18.0) 512 (38.3)
tients receiving tube thoracostomy. Similar results were found Admission
in patients who survived their ED stay (OR, 0.68; 95% CI, 0.52- SBP, median (IQR), mm Hg 90 (0-125) 110 (67-138)
0.89; P < .01), excluding severe traumatic brain injury (OR, 0.65; Heart rate, median (IQR), 88 (0-115) 94 (57-118)
beats/min
95% CI, 0.45-0.95; P = .03), and restricted to patients with se-
RR, median (IQR), 14 (0-22) 14 (0-22)
vere chest injury (OR, 0.72; 95% CI, 0.55-0.93; P = .01). For respirations/min
propensity score matching, 1236 patients who had PHND (92%) GCS score, median (IQR) 3 (3-15) 3 (3-14)
were matched to patients who received emergent tube thora- PRBC in ED, median (IQR) 0 (0-2) 0 (0-2)
costomy. The matching produced well-balanced groups Prehospital blood transfusion, 120 (1.7) 57 (4.3)
No. (%)
(Figure 2). In the matched cohort, PHND was associated with a Transport mode, No. (%)
21% decrease in the odds of 24-hour mortality (OR, 0.79; 95% Helicopter 1479 (26.1) 705 (52.8)
CI, 0.62-0.98; P = .04) (Table 2). When restricting matches to Ground 4181 (73.9) 629 (47.2)
within the same EMS agency, 968 patients who had PHND were Prehospital clinician level of care,
matched to control patients, with good balance of propensity No. (%)
BLS 151 (2.7) 4 (0.3)
score variables (OR, 0.74; 95% CI, 0.56-0.99; P = .04) (Figure 3).
ALS 5446 (97.3) 1325 (99.7)
Similarly, PHND was associated with a 26% reduction in the
Head AIS, median (IQR) 3 (2-4) 3 (2-5)
odds of 24-hour mortality (Table 2). Finally, instrumental vari-
Chest AIS, median (IQR) 3 (3-4) 3 (3-4)
able probit regression demonstrated that PHND was associ-
Abdomen AIS, median (IQR) 2 (2-4) 2 (1-4)
ated with lower 24-hour mortality (coefficient –0.60; 95% CI,
Pneumothorax diagnosis, No. (%) 3464 (48.6) 789 (59.0)
–1.04 to –0.16, P < .01). Results of the partial F test (F46, 2762
Hemothorax (only) diagnosis, 1175 (24.9) 206 (15.4)
(1−0.05) = 21.6; P < .01) and the Anderson-Rubin statistic con- No. (%)
fidence set (95% CI, –1.05 to –0.19 vs coefficient Wald 95% CI, 24-h Mortality, No. (%) 3261 (45.7) 471 (35.2)
–1.04 to –0.16) suggest that the instrument was not weak. In-hospital mortality, No. (%) 3679 (51.6) 583 (43.6)
In sensitivity analyses (Table 2), PHND was associated Abbreviations: AIS, abbreviated injury scale; ALS, advanced life support;
with lower odds of 24-hour mortality among patients that BLS, basic life support; ED, emergency department; GCS, Glasgow Coma Scale;
survived their ED stay, when excluding patients with severe ISS, injury severity score; PRBC, packed red blood cell; RR, respiratory rate;
SBP, systolic blood pressure.
head injury and when restricting to patients with severe a
Prehospital SBP less than 90 mm Hg.
chest injury. When including patients who were DOA, there b
Prehospital heart rate greater than 100 beats per minute.
were an additional 15 4 patients who had PHND and c
Prehospital RR less than 10 or greater than 29 respirations per minute.
102 patients who had tube thoracostomy, with PHND re-
maining associated with lower 24-hour mortality (Table 2).
The effect size of PHND on 24-hour mortality was greater transport (Table 2). PHND was also associated with lower
for helicopter transport but remained significant for ground 2-hour, 4-hour, and 6-hour mortality, whereas the 15-minute

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 Prehospital Needle Decompression and Mortality in Patients Requiring Chest Decompression
Table 2. Adjusted Odds Ratio (OR) of 24-Hour Mortality for Prehospital
Needle Decompression Compared With Tube Thoracostomy
Within 15 Minutes of Arrival at the Trauma Center
Characteristic aOR (95%CI)
Primary analysis 0.75 (0.61-0.94)
Propensity matched cohort 0.79 (0.62-0.98)
Propensity matched cohort within EMS agency 0.74 (0.56-0.99)
Survived ED stay 0.68 (0.52-0.89)
Excluded severe head injury 0.65 (0.45-0.95)
Severe chest injury 0.72 (0.55-0.93)
Documented pneumothorax 0.68 (0.49-0.95)
Including patients DOA (n = 8725) 0.67 (0.45-0.98)
Helicopter transport 0.67 (0.52-0.86)
Ground transport 0.77 (0.60-0.98)
Abbreviations: aOR, adjusted odds ratio; DOA, dead on arrival; ED, emergency
department; EMS, emergency medical services.
threshold for tube thoracostomy appears to be appropriate
(eResults in the Supplement).
Discussion
Results of this cohort study suggest that PHND is a rarely per-
formed procedure, with less than 1% of all trauma patients from
the study period receiving this intervention. When evaluating
rates of PHND in potentially eligible patients requiring emer-
gent chest decompression, only 11% received decompression.
After assessing variation in rates of PHND, we found that the ma-
jority of variation was attributable to EMS agency factors. This
trend was more pronounced among patients requiring emer-
gent chest decompression. Overall, PHND was associated with
a 25% decrease in odds of mortality at 24 hours compared with
emergent tube thoracostomy placement within 15 minutes of
patient arrival at the trauma center, and this finding persisted
in several methodologic approaches and sensitivity analyses.
We also found a different association between PHND and mor-
tality for patients transported by helicopter compared with
ground, which may be related to greater training and experi-
ence for helicopter EMS clinicians, potentially translating to
differences in patient selection and/or procedural success;
however, this requires further investigation.
Our rates of PHND were similar to those of prior work, rang-
ing from 0.2% to 1.7% of trauma patients, depending on the
population studied.7,8,15,16 The presence of hypotension be-
fore PHND varied widely from 7.9% to 86%7,17; however, most
studies report prehospital hypotension rates between 25% and
50%,8,10,18 more in line with the third of patients with prehos-
pital hypotension reported here.
One of the difficulties in studying PHND was the lack of a
comparison group, which hampered a robust assessment of the
potential impact on outcomes. EMS clinicians empirically per-
form PHND for patients who present with signs and symptoms
of tension pneumothorax, but it is difficult to determine if these
patients actually have tension pneumothorax leading to abnor-
mal physiology. Thus, prior work is largely descriptive of pa-
tients undergoing PHND. Many prior studies report on clinical
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Original Investigation Research
improvement after PHND and technical success rates of pleural
cavity decompression. Clinical improvement rates vary consid-
erably between studies, ranging from 5.7% to 53% after
PHND.7,10,16,18,19 Several studies reported that improvements in
P value
dyspnea and hypoxia were more common than improvement in
.01
hemodynamic parameters,7,10,18 although patients with hypo-
.04
tension have a 3-fold higher odds of having improvement in
.04
blood pressure than patients without hypotension before
<.01
PHND.16 We found comparable rates of physiologic improve-
.03
ment after PHND, with one-third of patients having at least 1
.01
physiologic abnormality improving. Success of pleural decom-
.02
pression is also highly variable, ranging from 5.9% to 100% with
.04 a bimodal distribution of mostly greater than 80% or less than
<.01 25% success rates among studies.19 Complication rates of PHND
.03 range from 2% to 13.7%, including iatrogenic pneumothorax or
hemothorax, subcutaneous hematoma, and dislodgement or
kinking of the catheter, leading to hemodynamic compromise.7,17
Reported mortality rates after PHND range from 12% to 79% and
are universally lower in patients not presenting in traumatic
arrest.9,19 Davis and colleagues18 found that an improvement in
systolic blood pressure after PHND was associated with im-
proved odds of survival, whereas Warner et al8 found 4 unex-
pected survivors who obtained return of spontaneous circula-
tion after PHND.
To facilitate outcome assessment for PHND, we chose our
comparison group to account for trauma patients with the per-
ceived need for emergent chest decompression who could have
been candidates for PHND. We believe this comparison group
represented patients who may have benefited from PHND and
allowed us to assess the association of the PHND interven-
tion with outcomes among trauma patients who required emer-
gent chest decompression.
Our data suggest that PHND was an effective procedure;
however, only 11% of potentially eligible patients received this
intervention. Although many factors may influence this and in-
dications for decompression may have arisen late in transport
or after arrival, EMS clinicians should have a high index of sus-
picion when considering tension pneumothorax in the setting
of chest trauma and consider PHND. This is similar to a recom-
mendation that was made by the 2018 Tactical Combat Casu-
alty Care guidelines, which advocate for an aggressive ap-
proach to suspecting and treating tension pneumothorax based
on mechanism of injury and respiratory distress.20 Patients who
had PHND tended to have more severe presentations, but our
analysis demonstrated that patients who had better prognostic
indicators still received emergent tube thoracostomy and likely
had tension pneumothorax. Prehospital procedures remain con-
troversial with several authors failing to find benefit.11,12 PHND
is distinct from some prehospital procedures, such as intuba-
tion, which add time at the scene of the injury and can induce
periprocedural harm from hypoxia and/or hypotension. PHND
can be performed en route with lower risk of harm. Further, much
support of scoop-and-run approaches come from urban set-
tings with penetrating trauma. Of note, more than 70% of the
PHND cases in this study were performed in patients with blunt
mechanism of injury, which may affect the results seen here.
When considering the variation that we see in rates of
PHND, there is area for improvement at the EMS agency level.
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 Research Original Investigation Prehospital Needle Decompression and Mortality in Patients Requiring Chest Decompression

Figure 2. Absolute Standardized Differences Between Prehospital Needle Decompression Group

and Emergent Tube Thoracostomy Group Before and After Matching in Propensity Score Variables

Transport mode
Prehospital intubation
Mechanism
Prehospital SBP
Prehospital clinician level Before matching
Prehospital heart rate After matching

Prehospital time
Prehospital GCS score
Absolute standardized differences
Prehospital blood less than 0.1 (vertical dashed line) are
Prehospital RR considered to represent good
balance of covariates between
0 0.2 0.4 0.6 groups after matching. GCS indicates
Absolute standardized difference Glasgow Coma Scale; RR, respiratory
rate; SBP, systolic blood pressure.

Figure 3. Absolute Standardized Differences Between Prehospital Needle Decompression Group

and Emergent Tube Thoracostomy Group Before and After Matching in Propensity Score Variables
Within Emergency Medical Services Agency

Prehospital intubation
Mechanism
Prehospital SBP
Prehospital clinician level
Before matching
Prehospital heart rate
After matching
Prehospital time
Prehospital GCS score
Absolute standardized differences
Prehospital blood less than 0.1 (vertical dashed line) are
Prehospital RR considered to represent good
balance of covariates between
0 0.1 0.2 0.3 0.4 groups after matching. GCS indicates
Absolute standardized difference Glasgow Coma Scale; RR, respiratory
rate; SBP, systolic blood pressure.

This variation underscores the need for thorough education
and quality assurance and performance-improvement pro-
grams within EMS agencies along with timely follow-up on pa-
tient outcomes at the trauma center. Further, incorporating
simulation or cadaver-based training for EMS clinicians may
facilitate successful placement more often than didactic train-
ing alone.21 Ultimately, a standardized approach to address-
ing tension pneumothorax in the prehospital setting should
be implemented to reduce variability and improve outcomes.
Recent advances in the type of catheter22-25 and anatomic po-
sition for PHND placement26-28 may improve success. The
evolving role of prehospital point-of-care ultrasound may im-
prove patient selection for PHND.29
Limitations
This study had several limitations. We cannot conclude cau-
sation between PHND and 24-hour survival because of the
retrospective observational nature of this study. We were un-
able to reliably determine laterality or if bilateral PHND was
performed based on ICD coding, as well as whether a subse-
quent chest tube was placed on the same side as the PHND.
We were also unable to determine the anatomic site where
PHND was performed, and we do not have data on procedure-
specific complications. Similarly, identification of an actual
pneumothorax and distinction from hemothorax relies on ICD
coding and may undercode these diagnoses. There are also sev-
eral assumptions that were made about the comparison group,
namely, the presence of tension pneumothorax. Some pa-
tients may have received tube thoracostomy as a proactive
measure at the trauma center before imaging, and we cannot
confirm that every patient had tension pneumothorax. Addi-
tionally, these patients may have deteriorated just before or
on arrival to the trauma center and thus did not meet the in-
dications for PHND by EMS clinicians at the trauma scene or
during transport. PTOS does not include data on indications
for PHND. We also did not have data on field hypoxia or dys-
pnea. The timing of prehospital vital signs relative to PHND was
not available, thus, although only one-third of patients un-
dergoing PHND experienced hypotension, it is unclear whether
this SBP was taken before or after the procedure. Similarly, most
patients who had PHND experienced an improvement in vital
signs by the time they arrived at the trauma center, but it re-
mains unclear if PHND was solely responsible. We also did not
have qualitative data about respiratory effort or distress. Al-
though we implemented various statistical measures to miti-
gate for confounding and selection bias, the reduction in mor-
tality associated with PHND may be a proxy for more aggressive
prehospital trauma care overall. Our results matching pa-

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 Prehospital Needle Decompression and Mortality in Patients Requiring Chest Decompression
tients within EMS agency to remove agency-level variation
engenders confidence in the results presented here. Despite
these limitations, our derivation of a comparison group of
patients requiring emergent chest decompression was a novel
method to allow the assessment of outcomes and we believe
adds to the literature surrounding PHND in trauma patients.
Conclusions
Results of this cohort study suggest that PHND was associated
with lower 24-hour mortality compared with emergent
ARTICLE INFORMATION
Accepted for Publication: May 30, 2022.
Published Online: August 17, 2022.
doi:10.1001/jamasurg.2022.3552
Author Contributions: Dr Brown had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Concept and design: Muchnok, Vargo, Deeb, Brown.
Acquisition, analysis, or interpretation of data:
Muchnok, Guyette, Brown.
Drafting of the manuscript: Muchnok, Brown.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Deeb, Brown.
Administrative, technical, or material support:
Vargo, Guyette, Brown.
Supervision: Brown.
Conflict of Interest Disclosures: None reported.
Additional Information: These data were provided
by the Pennsylvania Trauma Systems Foundation,
Mechanicsburg, Pennsylvania. The Foundation
specifically disclaims responsibility for any analyses,
interpretations, or conclusions.
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