Health & Human Services

Emergency Medical Services

Example of Research Paper


Thoracic Outlet Syndrome
Research Paper
Chet Ranzau, MICT-S
Cowley County Community College

Thoracic Outlet Syndrome (TOS) is defined by Richard J. Sanders, M.D., as neurovascular symptoms in the upper extremities due to pressure on the nerves and vessels in the thoracic outlet area. The specific structures compressed are usually the nerves of the brachial plexus and occasionally the subclavian artery or the subclavian vein (Appendix A). TOS is more common in women from 35-45 years of age. The pathogenesis of TOS is unknown.

I was first made aware of TOS, when I received an EMS call to a person that was diagnosed with TOS. This person had just came back from XX, where the surgeons resected the cervical and first rib, and placed an artificial subclavian artery due to numerous blood clots caused by the pressure that was put on the subclavian artery. This person was in severe pain and was having difficulty breathing. This person stated that it felt like one of his ribs was touching his lungs and was getting ready to pop it. He was later diagnosed with a hemothorax. I had never heard of TOS before, and that is why I chose TOS for my research paper, so I could learn more about it.

TOS is usually caused by either auto accidents that cause whiplash injuries or repetitive stress in the workplace. However, in some people, these symptoms can occur without any obvious cause. Their symptoms can be caused by an extra rib, called a cervical rib, which is linked to the first rib by a fibrous band of tissue. Cervical ribs are formed from unusually long transverse processes at the seventh cervical vertebra. People with this cervical rib are 10 times more likely to develop the symptoms, however requires some type of neck injury to bring on the symptoms.

Symptoms can range from a variety of things, depending on what structure is being compressed. If the brachial plexus is being compressed, the symptoms can include upper extremity pain, paresthesia on elevation of arms or anginal chest pain. If the subclavian artery is involved, numbness and tingling of arms and hands can occur. When the artery is being compressed for a long time, an aneurysm and/or thrombosis may develop with distal embolization. Subclavian vein compression can show swelling of arms and hands and a heaviness feeling to the effected upper extremity. Compression of the brachial plexus is the most common and may or may not be associated with venous or arterial compressions.

Many patients have mild to moderate sensory impairments in the C-8 to T-1 nerves.

Diagnosis of TOS is usually done with Selmonsky Triad, which is tenderness in the supraclavicular area, hand paleness and/or paresthesia on elevation and adduction and abduction weakness of fingers 4&5. One method that was thought to be an important diagnostic sign was the Adson's sign. Adson's sign is the loss of a radial pulse when the head is turned to one side or the arm is elevated. It was found to be unreliable since normal people tend to lose their pulse in the same position, and most people with TOS do not lose their pulse in these positions.

Treatment for TOS is the right diagnosis. Cervical spondylosis (pinched nerve at the spinal level), needs to be ruled out first, as do many other conditions, before treatment of TOS. When TOS is determine, the first route of treatment is physical therapy. In some cases, in which physical therapy is not the answer, surgery, a last resort, can be done. When surgery is the answer, a resection of the cervical and/or first rib is performed. In over 70% of the people diagnosed with TOS, improve without the need for surgery. The improvement rate of TOS with surgery, with auto injuries as the cause, is 80-85% success rate, while repetitive stress as the cause, there is a 60-70% success rate.

As far as treatment for EMS, there isn't anything special, except for treating symptomatically. We, as EMS providers should be aware of this unique condition. Even though it doesn't sound bad, but it could possibly be very detrimental to a patients life. For example, if an embolus should happen to form from a compression of an artery or a vein, as stated before, it could break lose and cause a Pulmonary Emboli. We should also be aware of it, since one of the many possible symptoms is anginal chest pain. We can add this condition to our long list of different types of chest pain, that we use to differentiate between, even though it is a very big zebra that we would be chasing.

Research of any topic is an important issue that we must do in order to be an excellent healthcare provider. We owe it to out patients to be on top of it and have, at least, some knowledge of the zebras that are out there. Just like this topic, that I have chosen, it is a subject that most physicians have just the vaguest notion of. But, I didn't know what it was, and at the time, didn't know if it was detrimental to my patient, or if any specific treatment was detrimental either. So research is important, even if it isn't just for grade in a MICT program, but it also enhances our knowledge base so we can be excellent healthcare providers.

[The student used 8 references -- Images are also not attached]
A special thanks to Chet for allowing this to be used for an example for future MICT students.