Prehospital Needle Thoracostomies in Traumatic Cardiac Arrest: Forensic Insights into Procedural Performance and Successes

Background Tension pneumothorax is a life-threatening condition in trauma patients requiring rapid recognition and treatment. Needle thoracostomy (NT) is a critical prehospital intervention to treat this condition. Objective To evaluate prehospital NT performance through medical examiner (ME) assessment of anatomical placement, pleural space access, and complications in prehospital nontransported traumatic cardiac arrest patients. Methods A prospective observational study reviewed 144 prehospital NTs performed on 77 patients after initial emergency medical service (EMS) care from 01 February, 2022 to 16 June, 2024. NTs were evaluated during autopsy for placement within recommended external anatomical landmarks, pleural space entry, and evidence of complications. EMS documentation was reviewed to correlate findings. Results Of 124 lateral chest wall NTs, 35.5% were outside of recommended anatomic landmarks and 34.6% did not access the pleural space, with a 14.5% complication rate. Among 20 anterior chest wall NTs, 10% had incorrect external placement and 80.0% did not access the pleural space, with a 5.0% complication rate. When comparing lateral chest wall NTs to anterior chest wall NTs the difference in correct external placement ( P = .036) and pleural access ( P < .001) were statistically significant but the complication rates ( P = .474) were not. Conclusion Autopsy-based review provides valuable insight into the real-world performance of prehospital NTs. Lateral chest wall NTs have high rates of incorrect external anatomic placement but more often access the pleural space as compared to anterior chest wall NTs. Complications are rare overall. This collaborative model between the ME and EMS can identify trends and challenges, inform training, guideline development and system-level improvements.