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Blythe NM, Coates K, Benger JR, Annaw A, Banks J, Clement C, Clout M, Edwards A, Gaunt D, Kandiyali R, Lane JA, Lecky F, Maskell NA, Metcalfe C, Platt M, Rees S, Taylor J, Thompson J, Walker S, West D, Carlton E. Conservative management versus invasive management of significant traumatic pneumothoraces in the emergency department (the CoMiTED trial): a study protocol for a randomised non-inferiority trial. BMJ Open 2024; 14:e087464. [PMID: 38889939 PMCID: PMC11191772 DOI: 10.1136/bmjopen-2024-087464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/21/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Traumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician's discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces. METHODS AND ANALYSIS The CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months. ETHICS AND DISSEMINATION This trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN35574247.
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Affiliation(s)
| | | | - Jonathan R Benger
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- University of the West of England, Bristol, UK
| | - Ammar Annaw
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jonathan Banks
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | | | | | - Daisy Gaunt
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - J Athene Lane
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Fiona Lecky
- The University of Sheffield, Sheffield, UK
- Salford Royal NHS Trust, Salford, UK
| | - Nick A Maskell
- North Bristol NHS Trust, Bristol, UK
- University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Marie Platt
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sophie Rees
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jodi Taylor
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Steven Walker
- North Bristol NHS Trust, Bristol, UK
- University of Bristol, Bristol, UK
| | - Douglas West
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Edward Carlton
- North Bristol NHS Trust, Bristol, UK
- University of Bristol, Bristol, UK
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Pokrzywa CJ, Figueroa J, Gomez J, Karam B, Murphy P, Iverson K, Morris R, Carver T, Milia D, de Moya M. Mechanical Ventilation Does Not Predict Pneumothorax Observation Failure in the Severely Injured. Am Surg 2023; 89:5246-5252. [PMID: 36448872 DOI: 10.1177/00031348221142583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Observative management of small traumatic pneumothoraces (PTX) has been shown to decrease chest tube utilization in non-mechanically ventilated patients without compromising outcomes. This approach could be used in mechanically ventilated (MV) patients, though many feel these patients are at increased risk of observation failure. METHODS A single center retrospective study of all adults undergoing observation of a computed tomography (CT) diagnosed PTX from 2015-2019. Patients with chest tube placement within 4-hours of arrival, concurrent hemothorax, or death within 24-hours were excluded. Observation failure was defined as chest tube placement. RESULTS Of 340 patients, 64 were on MV. The groups were of similar age, BMI, underlying pulmonary comorbidities, and PTX size (10.1 mm vs 8.8 mm, P = .20). The MV group was more severely injured (ISS [25+] [60.9% vs 11.2%, P < .001]). There was no difference in observation failure rates by MV status overall (6.3% vs 5.1%, P = .75) or by PTX size (<15 mm [5% vs 2.2%, P = .37], <20 mm [4.8% vs 3.1%, P = .45], <25 mm [4.8% vs 4.1%, P = .73], <30 mm [4.8% vs 4.1%, P = .73], <35 mm [4.8% vs 4.7%, P = 1.00]). MV was not an independent predictor of observation failure on multivariable analysis (OR .64, 95% CI .18-2.20), though PTX size was (OR 1.11, 95% CI 1.05-1.17). When comparing those who failed vs those who did not, the only difference was PTX size (9.34 mm vs 19.41 mm, P < .001). CONCLUSION MV is not an independent predictor of PTX observation failure. While PTX size appears to play a role, further studies are needed to outline safe parameters for observation in those undergoing MV.
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Affiliation(s)
| | - Juan Figueroa
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jose Gomez
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Basil Karam
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Patrick Murphy
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Katie Iverson
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tom Carver
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Milia
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marc de Moya
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Shriki J, Dave SB. Minor Procedures in Trauma. Emerg Med Clin North Am 2023; 41:143-159. [DOI: 10.1016/j.emc.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Letter to the Editor: Western Trauma Association Critical Decision Algorithm for the Evaluation and Management of Traumatic Pneumothorax. J Trauma Acute Care Surg 2022; 93:e147-e148. [PMID: 35653501 DOI: 10.1097/ta.0000000000003659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Occult traumatic pneumothorax: Is routine follow up chest X-ray necessary? SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Reply to Letter to the Editor: Western Trauma Association Critical Decision Algorithm for the Evaluation and Management of Traumatic Pneumothorax. J Trauma Acute Care Surg 2022; 93:e148-e149. [PMID: 35647815 DOI: 10.1097/ta.0000000000003716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mohrsen S, McMahon N, Corfield A, McKee S. Complications associated with pre-hospital open thoracostomies: a rapid review. Scand J Trauma Resusc Emerg Med 2021; 29:166. [PMID: 34863280 PMCID: PMC8643006 DOI: 10.1186/s13049-021-00976-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/04/2021] [Indexed: 02/26/2023] Open
Abstract
Background Open thoracostomies have become the standard of care in pre-hospital critical care in patients with chest injuries receiving positive pressure ventilation. The procedure has embedded itself as a rapid method to decompress air or fluid in the chest cavity since its original description in 1995, with a complication rate equal to or better than the out-of-hospital insertion of indwelling pleural catheters. A literature review was performed to explore potential negative implications of open thoracostomies and discuss its role in mechanically ventilated patients without clinical features of pneumothorax. Main findings A rapid review of key healthcare databases showed a significant rate of complications associated with pre-hospital open thoracostomies. Of 352 thoracostomies included in the final analysis, 10.6% (n = 38) led to complications of which most were related to operator error or infection (n = 26). Pneumothoraces were missed in 2.2% (n = 8) of all cases. Conclusion There is an appreciable complication rate associated with pre-hospital open thoracostomy. Based on a risk/benefit decision for individual patients, it may be appropriate to withhold intervention in the absence of clinical features, but consideration must be given to the environment where the patient will be monitored during care and transfer. Chest ultrasound can be an effective assessment adjunct to rule in pneumothorax, and may have a role in mitigating the rate of missed cases. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00976-1.
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Affiliation(s)
- Stian Mohrsen
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK. .,Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK9 4LA, Scotland, UK.
| | - Niall McMahon
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK
| | - Alasdair Corfield
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK
| | - Sinéad McKee
- Department of Nursing, School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
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Abstract
Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.
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