1
|
Becker L, Schulz-Drost S, Schreyer C, Lindner S. [Chest Tube in Thoracic Trauma - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU)]. Zentralbl Chir 2023; 148:57-66. [PMID: 36849110 DOI: 10.1055/a-1975-0243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH2O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.
Collapse
Affiliation(s)
- Lars Becker
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Stefan Schulz-Drost
- Klinik für Unfallchirurgie und Traumatologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Christof Schreyer
- Allgemein-/Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Koblenz, Deutschland
| | - Sebastian Lindner
- Klinik für Thoraxchirurgie und thorakale Endoskopie, HELIOS Klinikum Erfurt, Erfurt, Deutschland
| |
Collapse
|
2
|
Huang JF, Hsu CP, Fu CY, Ou Yang CH, Cheng CT, Liao CH, Kuo IM, Hsieh CH. Is massive hemothorax still an absolute indication for operation in blunt trauma? Injury 2021; 52:225-230. [PMID: 33386159 DOI: 10.1016/j.injury.2020.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/18/2020] [Accepted: 12/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgery is usually suggested to treat massive haemothorax (MHT). The MHT criteria are based on penetrating trauma observations in military scenarios; the need for surgery in blunt trauma patients remains questionable. This study aimed to determine the characteristics of blunt trauma patients with MHT who required surgery. METHODS Patients who presented to the emergency department (ED) with traumatic haemothorax or pneumothorax, heart and lung injuries, and thoracic blood vessel injuries from Jan 1, 2014, to Dec 31, 2018, were reviewed. The inclusion criterion was a chest tube drainage amount that met the MHT criteria. Therapeutic operations were defined as those involving surgical haemostasis; otherwise, operations were considered non-therapeutic. The non-therapeutic operation group included the patients who received nonoperative management. The characteristics of the therapeutic and non-therapeutic operation groups were compared. RESULTS Forty-four patients were enroled in the study. Six patients received conservative treatment and were discharged uneventfully. Eleven patients underwent non-therapeutic operations. The patients with surgical bleeding had a high pulse rate (125.0 (111.0, 135.0) vs. 116.0 (84.0, 121.0) bpm, p = 0.013); low systolic blood pressure (SBP) after resuscitation (106.0 (84.0, 127.0) vs. 121.0 (116.0, 134.0) mmHg, p = 0.040); low pH (7.2 (7.2, 7.3) vs. 7.4 (7.3, 7.4), p = 0.002); and low bicarbonate (17.8 (14.6, 21.5) vs. 21.4 (17.0, 21.5) mEq/L, p = 0.038), low base excess (-9.1 (-13.4, -4.5) vs. -3.8 (-10.1, -0.7), p = 0.028), and high lactate (5.7 (3.3, 7.8) vs. 1.8 (1.7, 2.8) mmol/L, p = 0.002) levels. CONCLUSION Conservative treatment could be performed selectively in patients with MHT. Lactate could be a predictor of the need for surgical intervention in blunt trauma patients with MHT.
Collapse
Affiliation(s)
- Jen-Fu Huang
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chih-Po Hsu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan.
| | - Chun-Hsiang Ou Yang
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chi-Tung Cheng
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chien-Hung Liao
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - I-Ming Kuo
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| | - Chi-Hsun Hsieh
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan
| |
Collapse
|
3
|
Abstract
BACKGROUND Tube thoracostomy (TT) complications and their reported rates are highly variable (1-40%) and inconsistently classified. Consistent TT complication classification must be applied to compare reported literature to standardize TT placement. We aim to determine the overall TT-related complication rates in patients receiving TT for traumatic indications using uniform definitions. METHODS Systematic review and meta-analysis was performed assessing TT-related complications. Comprehensive search of several databases (1975-2015) was conducted. We included studies that reported on bedside TT insertion (≥22 Fr) in trauma patients. Data were abstracted from eligible articles by independent reviewers with discrepancies reconciled by a third. Analyses were based on complication category subtypes: insertional, positional, removal, infection/immunologic/education, and malfunction. RESULTS Database search resulted in 478 studies; after applying criteria 29 studies were analyzed representing 4,981 TTs. Injury mechanisms included blunt 60% (49-71), stab 27% (17-34), and gunshot 13% (7.8-10). Overall, median complication rate was 19% (95% confidence interval, 14-24.3). Complication subtypes included insertional (15.3%), positional (53.1%), removal (16.2%), infection/immunologic (14.8%), and malfunction (0.6%). Complication rates did not change significantly over time for insertional, immunologic, or removal p = 0.8. Over time, there was a decrease in infectious TT-related complications as well as an increase in positional TT complications. CONCLUSION Generation of evidence-based approaches to improve TT insertion outcomes is difficult because a variety of complication classifications has been used. This meta-analysis of complications after TT insertion in trauma patients suggests that complications have not changed over time remaining stable at 19% over the past three decades. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
Collapse
|
4
|
Hernandez MC, Vogelsang D, Anderson JR, Thiels CA, Beilman G, Zielinski MD, Aho JM. Visually guided tube thoracostomy insertion comparison to standard of care in a large animal model. Injury 2017; 48:849-853. [PMID: 28238448 PMCID: PMC5427288 DOI: 10.1016/j.injury.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/03/2017] [Accepted: 02/17/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Tube thoracostomy (TT) is a lifesaving procedure for a variety of thoracic pathologies. The most commonly utilized method for placement involves open dissection and blind insertion. Image guided placement is commonly utilized but is limited by an inability to see distal placement location. Unfortunately, TT is not without complications. We aim to demonstrate the feasibility of a disposable device to allow for visually directed TT placement compared to the standard of care in a large animal model. METHODS Three swine were sequentially orotracheally intubated and anesthetized. TT was conducted utilizing a novel visualization device, tube thoracostomy visual trocar (TTVT) and standard of care (open technique). Position of the TT in the chest cavity were recorded using direct thoracoscopic inspection and radiographic imaging with the operator blinded to results. Complications were evaluated using a validated complication grading system. Standard descriptive statistical analyses were performed. RESULTS Thirty TT were placed, 15 using TTVT technique, 15 using standard of care open technique. All of the TT placed using TTVT were without complication and in optimal position. Conversely, 27% of TT placed using standard of care open technique resulted in complications. Necropsy revealed no injury to intrathoracic organs. CONCLUSION Visual directed TT placement using TTVT is feasible and non-inferior to the standard of care in a large animal model. This improvement in instrumentation has the potential to greatly improve the safety of TT. Further study in humans is required. LEVEL OF EVIDENCE Therapeutic Level II.
Collapse
Affiliation(s)
- Matthew C. Hernandez
- Department of Surgery, Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | | | | | | | - Gregory Beilman
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Martin D. Zielinski
- Department of Surgery, Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | - Johnathon M. Aho
- Department of Surgery, Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| |
Collapse
|
5
|
Abstract
Clinical suspicion of hemo/pneumothorax: when in doubt, drain the chest. Stable chest trauma with hemo/pneumothorax: drain and wait. Unstable patient with dislocated trachea must be approached with drain in hand and scalpel ready. Massive hemo/pneumothorax may be controlled by drainage alone. The surgeon should not hesitate to open the chest if too much blood drains over a short period. The chest drainage procedure does not end with the last stitch; the second half of the match is still ahead. The drained patient is in need of physiotherapy and proper pain relief with an extended pleural space: control the suction system.
Collapse
Affiliation(s)
- Tamas F Molnar
- Department of Operational Medicine, Faculty of Medicine, University of Pécs, H7622 Pécs, Szigeti út 12, Hungary; Thoracic Surgery Unit, Department of Surgery, Aladar Petz Teaching Hospital, H9032 Győr, Vasvari Pál utca 2-4, Hungary.
| |
Collapse
|
6
|
Katballe N, Moeller LB, Olesen WH, Litzer MM, Andersen G, Nekrasas V, Licht PB, Bach P, Pilegaard HK. A Novel Device for Accurate Chest Tube Insertion: A Randomized Controlled Trial. Ann Thorac Surg 2015; 101:527-32. [PMID: 26409714 DOI: 10.1016/j.athoracsur.2015.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/03/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Optimal positioning of a large-bore chest tube is in the part of the pleural cavity that needs drainage. It is recommended that the chest tube be positioned apically in pneumothorax and basally for fluids. However, targeted chest tube positioning to a specific part of the pleural cavity can be a challenge. METHODS A new medical device, the KatGuide, was developed for accurate guiding of a chest tube (28F) to an intended part of the pleural cavity. The primary end point of this randomized, controlled trial was optimal position of the chest tube. The optimal position in pneumothorax was apical (above the aortic arch), and the optimal position in hemothorax, hydrothorax, chylothorax, or empyema was basal (2 cm above the diaphragm or lower). The patients were randomized for the KatGuide method or the conventional forceps method, and rates of optimal position were compared. RESULTS A total of 109 patients were enrolled (KatGuide: n = 49; conventional: n = 60). Chest tubes were optimally position in 41 (84%) in the KatGuide group vs 32 (53%) in the conventional group (p = 0.001). Experienced operators (>50 previous chest tube insertions) inserted 39 of the chest tubes, of which, 15 of 17 (88%) were optimally positioned in the KatGuide group vs 11 of 22 (50%) in the conventional group (p = 0.02). Two chest tubes (4%) were misplaced in the KatGuide group vs 11 (18%) in the conventional group (p = 0.04). No adverse device effects were observed. CONCLUSIONS The KatGuide significantly improves the probability of optimal chest tube position and reduces the risk of misplacement compared with the conventional method. ClinicalTrial.gov Trial Registration Number: NCT01522885.
Collapse
Affiliation(s)
- Niels Katballe
- Department of Cardiothoracic and Vascular Surgery and Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Lars B Moeller
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Winnie H Olesen
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Marina M Litzer
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Gratien Andersen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Vytautas Nekrasas
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Peter B Licht
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Peter Bach
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Hans K Pilegaard
- Department of Cardiothoracic and Vascular Surgery and Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
7
|
Martinez T, Pasquier P, Swiech A, Kearns K, Dubost C, Mérat S. Lung Ultrasound for Chest Tube Insertion. Am J Emerg Med 2015; 33:1095-6. [DOI: 10.1016/j.ajem.2015.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/11/2015] [Accepted: 04/16/2015] [Indexed: 11/29/2022] Open
|
8
|
Çubuk S, Yücel O. Importance of tube position after tube thoracostomy. Am J Emerg Med 2015; 33:592. [PMID: 25661100 DOI: 10.1016/j.ajem.2015.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 01/15/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sezai Çubuk
- Gata Medical Faculty, Department of Thoracic Surgery, Ankara, Turkey.
| | - Orhan Yücel
- Gata Haydarpasa Teaching Hospital, Department of Thoracic Surgery, Istanbul, Turkey
| |
Collapse
|