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Bettoni G, Gheda S, Altomare M, Cioffi SPB, Ferrazzi D, Cazzaniga M, Bonacchini L, Cimbanassi S, Aseni P. Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:548. [PMID: 38674194 PMCID: PMC11051943 DOI: 10.3390/medicina60040548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/20/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024]
Abstract
Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.
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Affiliation(s)
- Giuseppe Bettoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Silvia Gheda
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Michele Altomare
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, 00185 Rome, Italy; (M.A.); (S.P.B.C.)
- General Surgery Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Stefano Piero Bernardo Cioffi
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, 00185 Rome, Italy; (M.A.); (S.P.B.C.)
- General Surgery Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Davide Ferrazzi
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Michela Cazzaniga
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Luca Bonacchini
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
| | - Stefania Cimbanassi
- General Surgery Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Paolo Aseni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (G.B.); (S.G.); (D.F.); (M.C.); (L.B.)
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy
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Lieurance R, Scheatzle M, Johnjulio WA, O’Neill J. Point-of-care ultrasound thoracic “Quick Look” identifies potentially dangerous chest tube insertion sites. Eur J Trauma Emerg Surg 2022; 49:777-783. [PMID: 36287239 DOI: 10.1007/s00068-022-02109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Emergency and trauma physicians typically rely on anatomic landmarks to determine the proper intercostal space for emergent tube thoracostomy. However, physicians using this technique select a potentially dangerous insertion site too inferior in nearly one-third of cases, which have the potential to result in subdiaphragmatic puncture. We investigated a point-of-care ultrasound (POCUS) thoracic "Quick Look" procedure as a technique to allow visualization of underlying structures to avoid tube misplacement. METHODS We performed an observational study of adult emergency department patients and their treating physicians. The patient's emergency physician was asked to rapidly identify and mark a hypothetical tube thoracostomy insertion site on the patient's chest wall. An ultrasound fellow then performed a POCUS thoracic "Quick Look" exam with a phased-array probe placed directly over the marked site. Over one regular respiratory cycle, the identification of standard lung pattern was considered a negative scan whereas visualization of the diaphragm with underlying liver or spleen was considered a positive scan. Time for completion of the "Quick Look" scan was measured and inter-rater reliability was determined through image review by a single, blinded ultrasound director. RESULTS Seventy-six thoracic "Quick Look" scans were performed on patient subjects, of which 17% (13/76, 95%CI 8-26%) were positive. The average time for performing the "Quick Look" exam was 43 s (95%CI 30-57). Inter-rater reliability of the thoracic "Quick Look" was excellent (κ = 0.95). CONCLUSION Thoracic "Quick Look" exams performed at mock chest tube insertion sites demonstrated potentially dangerous insertions in 17% of the cases. POCUS thoracic "Quick Look" may be a rapid and reliable technique that improves safety when placing an emergent chest tube.
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Osuchukwu O, Lopez J, Weaver KL, Waddell VA, Aguayo P, St Peter SD, Juang D. Asymptomatic non-occult pneumothorax in pediatric blunt chest trauma: Chest tube versus observation. J Pediatr Surg 2021; 56:2333-2336. [PMID: 33648730 DOI: 10.1016/j.jpedsurg.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/19/2021] [Accepted: 02/05/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The treatment of asymptomatic non-occult pneumothoraces (ANOPTX) secondary to blunt chest trauma (BCT) has not been well delineated. We sought to analyze our experience with ANOPTX in pediatric trauma patients and determine if a chest tube (CT) is mandatory. METHODS A retrospective chart review of patients < 17 years old with ANOPTX from BCT who presented to a level 1 trauma children's hospital, between January 2000 and June 2015 was performed. Demographics, vitals, trauma scores, imaging, interventions, hospital expenses and outcomes were analyzed. RESULTS Of the 77 patients who had ANOPTX, 48 (62.3%) were managed with observation only, while 29 (37.7%) underwent CT placement. The median length of stay for patients who had CT placement was 7 days (IQR, 4, 12) and 2 days (IQR, 1, 4) in those observed (p < 0.01). All patients who were observed had complete resolution of the pneumothorax without recurrence or the need for CT placement. Patients who had CT placement had more imaging performed and more hospital expenditure compared to those who were observed. CONCLUSIONS CT is not mandatory in all pediatric patients with ANOPTX from BCT and observation has been found to be safe and cost effective.
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Affiliation(s)
- Obiyo Osuchukwu
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Joseph Lopez
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Katrina L Weaver
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Valerie A Waddell
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA.
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Beattie G, Cohan CM, Chomsky-Higgins K, Tang A, Senekjian L, Victorino GP. Is a chest radiograph after thoracostomy tube removal necessary? A cost-effective analysis. Injury 2020; 51:2493-2499. [PMID: 32747140 DOI: 10.1016/j.injury.2020.07.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/24/2020] [Accepted: 07/25/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Following placement of tube thoracostomy (TT) for evacuation of traumatic hemopneumothorax (HPTX), controversy persists over the need for routine post-TT removal chest radiograph (CXR). Current research demonstrates routine CXR may offer no advantage over clinical observation alone while simultaneously increasing hospital resource utilization. As such, we hypothesized that in resolved traumatic HPTXs routine post-TT removal CXR to assess recurrent PTX compared to clinical observation is not cost-effective. METHODS We performed a decision-analytic model to evaluate the cost-effectiveness of routine CXR compared to clinical observation following TT removal. Our base case was a patient that sustained thoracic trauma with radiographic and clinical resolution of HPTX following TT evacuation. Cost, utility and probability estimates were generated from published literature, with costs represented in 2019 US dollars and utilities in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed. RESULTS Decision-analytic model identified that clinical observation after TT removal was the dominant strategy with increased benefit at less cost, when compared to routine CXR, with a net cost of $194.92, QALYs of 0.44. In comparison, routine CXR demonstrated an increase of $821.42 in cost with 0.43 QALYs. On probabilistic sensitivity analysis the clinical observation strategy was found cost-effective in 99.5% of 10,000 iterations. CONCLUSION In trauma patients with clinical and radiographic evidence of a resolved HPTX, the adoption of clinical observation in lieu of post-TT removal CXR is cost-effective. Routine CXR following TT removal accrues more cost without additional benefit. The practice of routinely obtaining a CXR following TT removal should be scrutinized.
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Affiliation(s)
- Genna Beattie
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Caitlin M Cohan
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Kathryn Chomsky-Higgins
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Annie Tang
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Lara Senekjian
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Gregory P Victorino
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
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Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: An overview. Chin J Traumatol 2020; 23:125-138. [PMID: 32417043 PMCID: PMC7296362 DOI: 10.1016/j.cjtee.2020.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/15/2020] [Accepted: 04/08/2020] [Indexed: 02/04/2023] Open
Abstract
Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.
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Ahmed RA, Hughes PG, Wong AH, Gray KM, Ballas D, Khobrani A, Selley RD, McQuown C. Iatrogenic emergency medicine procedure complications and associated trouble-shooting strategies. Int J Health Care Qual Assur 2019; 31:935-949. [PMID: 30415624 DOI: 10.1108/ijhcqa-08-2017-0157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to provide a consolidated reference for the acute management of selected iatrogenic procedural injuries occurring in the emergency department (ED). DESIGN/METHODOLOGY/APPROACH A literature search was performed utilizing PubMed, Scopus, Web of Science and Google Scholar for studies through March of 2017 investigating search terms "iatrogenic procedure complications," "error management" and "procedure complications," in addition to the search terms reflecting case reports involving the eight below listed procedure complications. FINDINGS This may be particularly helpful to academic faculty who supervise physicians in training who present a higher risk to cause such injuries. ORIGINALITY/VALUE Emergent procedures performed in the ED present a higher risk for iatrogenic injury than in more controlled settings. Many physicians are taught error-avoidance rather than how to handle errors when learning procedures. There is currently very limited literature on the error management of iatrogenic procedure complications in the ED.
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Dickson RL, Gleisberg G, Aiken M, Crocker K, Patrick C, Nichols T, Mason C, Fioretti J. Emergency Medical Services Simple Thoracostomy for Traumatic Cardiac Arrest: Postimplementation Experience in a Ground-based Suburban/Rural Emergency Medical Services Agency. J Emerg Med 2018; 55:366-371. [PMID: 29958708 DOI: 10.1016/j.jemermed.2018.05.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/16/2018] [Accepted: 05/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Tube thoracostomy has long been the standard of care for treatment of tension pneumothorax in the hospital setting yet is uncommon in prehospital care apart from helicopter emergency medical services. OBJECTIVE We aimed to evaluate the performance of simple thoracostomy (ST) for patients with traumatic cardiac arrest and suspected tension pneumothorax. METHODS We conducted a retrospective case series of consecutive patients with traumatic cardiac arrest where simple thoracostomy was used during the resuscitation effort. Data were abstracted from our Zoll emergency medical record (Zoll Medical Corp., Chelmsford, MA) for patients who received the procedure between June 1, 2013 and July 1, 2017. We collected general descriptive characteristics, procedural success, presence of air or blood, and outcomes for each patient. RESULTS During the study period we performed ST on 57 patients. The mean age was 41 years old (range 15-81 years old) and 83% were male. Indications included 40 of 57 (70%) blunt trauma and 17 of 57 (30%) penetrating trauma. The presenting rhythm was pulseless electrical activity 65%, asystole 26%, ventricular tachycardia/fibrillation 4%, and nonrecorded 5%. Eighteen of 57 (32%) had air return, 14 of 57 (25%) return of spontaneous circulation, with 6 of 57 (11%) surviving to 24 h and 4 of 57 (7%) discharged from the hospital neurologically intact. Of the survivors, all were blunt trauma mechanism with initial rhythms of pulseless electrical activity. There were no reported medic injuries. CONCLUSIONS Our data show that properly trained paramedics in ground-based emergency medical services were able to safely and effectively perform ST in patients with traumatic cardiac arrest. We found a significant (32%) presence of pneumothorax in our sample, which supports previously reported high rates in this patient population.
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Affiliation(s)
| | | | - Michael Aiken
- Montgomery County Hospital District Emergency Medical Services, Houston, Texas
| | - Kevin Crocker
- Montgomery County Hospital District Emergency Medical Services, Houston, Texas
| | - Casey Patrick
- Montgomery County Hospital District Emergency Medical Services, Houston, Texas
| | - Tyler Nichols
- Baylor College of Medicine, Baylor University, Houston, Texas
| | | | - Joseph Fioretti
- Montgomery County Hospital District Emergency Medical Services, Houston, Texas
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Carson‐Chahhoud KV, Wakai A, van Agteren JEM, Smith BJ, McCabe G, Brinn MP, O'Sullivan R. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev 2017; 9:CD004479. [PMID: 28881006 PMCID: PMC6483783 DOI: 10.1002/14651858.cd004479.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND For management of pneumothorax that occurs without underlying lung disease, also referred to as primary spontaneous pneumothorax, simple aspiration is technically easier to perform than intercostal tube drainage. In this systematic review, we seek to compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax. This review was first published in 2007 and was updated in 2017. OBJECTIVES To compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library; MEDLINE (1966 to January 2017); and Embase (1980 to January 2017). We searched the World Health Organization (WHO) International Clinical Trials Registry for ongoing trials (January 2017). We checked the reference lists of included trials and contacted trial authors. We imposed no language restrictions. SELECTION CRITERIA We included randomized controlled trials (RCTs) of adults 18 years of age and older with primary spontaneous pneumothorax that compared simple aspiration versus intercostal tube drainage. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed trial quality, and extracted data. We combined studies using the random-effects model. MAIN RESULTS Of 2332 publications obtained through the search strategy, seven studies met the inclusion criteria; one study was ongoing and six studies of 435 participants were eligible for inclusion in the updated review. Data show a significant difference in immediate success rates of procedures favouring tube drainage over simple aspiration for management of primary spontaneous pneumothorax (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.69 to 0.89; 435 participants, 6 studies; moderate-quality evidence). Duration of hospitalization however was significantly less for patients treated by simple aspiration (mean difference (MD) -1.66, 95% CI -2.28 to -1.04; 387 participants, 5 studies; moderate-quality evidence). A narrative synthesis of evidence revealed that simple aspiration led to fewer adverse events (245 participants, 3 studies; low-quality evidence), but data suggest no differences between groups in terms of one-year success rate (RR 1.07, 95% CI 0.96 to 1.18; 318 participants, 4 studies; moderate-quality evidence), hospitalization rate (RR 0.60, 95% CI 0.25 to 1.47; 245 participants, 3 studies; very low-quality evidence), and patient satisfaction (median between-group difference of 0.5 on a scale from 1 to 10; 48 participants, 1 study; low-quality evidence). No studies provided data on cost-effectiveness. AUTHORS' CONCLUSIONS Available trials showed low to moderate-quality evidence that intercostal tube drainage produced higher rates of immediate success, while simple aspiration resulted in a shorter duration of hospitalization. Although adverse events were reported more commonly for patients treated with tube drainage, the low quality of the evidence warrants caution in interpreting these findings. Similarly, although this review observed no differences between groups when early failure rate, one-year success rate, or hospital admission rate was evaluated, this too needs to be put into the perspective of the quality of evidence, specifically, for evidence of very low and low quality for hospitalization rate and patient satisfaction, respectively. Future adequately powered research is needed to strengthen the evidence presented in this review.
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Affiliation(s)
- Kristin V Carson‐Chahhoud
- The University of South AustraliaSchool of Health SciencesCity East Campus, Frome RoadAdelaideAustralia5001
| | - Abel Wakai
- Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland (RCSI)Emergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
| | | | - Brian J Smith
- The Queen Elizabeth Hospital, Central Adelaide Local Health NetworkRespiratory Medicine UnitAdelaideAustralia
| | - Grainne McCabe
- Royal College of Surgeons in IrelandMercer Library23 St. Stephens Green,DublinIreland2
| | - Malcolm P Brinn
- The University of QueenslandHabit Research Group, School of Public HealthPublic Health Building, Herston RoadHerston RoadBrisbaneQueenslandAustralia4030
| | - Ronan O'Sullivan
- Cork University HospitalCorkIreland
- Our Lady's Children's Hospital CrumlinNational Children's Research CentreDublinIreland12
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Tube thoracostomy: Increased angle of insertion is associated with complications. J Trauma Acute Care Surg 2017; 81:366-70. [PMID: 27120327 DOI: 10.1097/ta.0000000000001098] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Tube thoracostomy (TT), considered a routine procedure, has significant complications. Current recommendations for placement rely on surface anatomy. There is no information to guide operators regarding angle of insertion relative to chest wall. We aim to determine if angle of insertion is associated with complications of TT. METHODS We performed a retrospective review of adult trauma patients who necessitated TT at a Level I trauma center over a 2-year period (January 2012 to December 2013). Tube thoracostomies performed intraoperatively or using radiological guidance were excluded. Thoracic anteroposterior or posteroanterior radiographs were reviewed to determine the angle of insertion of TT relative to the thoracic wall. A previously validated classification method was used to categorize complications. Descriptive and univariate statistics were used to compare angle of insertion and complicated versus uncomplicated TT. RESULTS Review identified 154 patients who underwent a total of 246 TT placed for emergent trauma. All patients had a postprocedural chest x-ray. We identified 90 complications (37%) over the study period. One hundred forty-four of the TTs reviewed had an angle of insertion less than 45 degrees of which there were 27 complications (19%). One hundred two of the TTs had an angle greater than 45 degrees and 63 complications (62%); p < 0.0001. CONCLUSIONS Tube thoracostomy insertion is inherently dangerous. Placement of TT using a higher angle of insertion greater than 45 degrees is associated with increased complications. Further prospective studies quantifying TT angle of insertion on outcomes are needed. LEVEL OF EVIDENCE Therapeutic study, level IV.
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An innovative pediatric chest tube insertion task trainer simulation: a technical report and pilot study. Simul Healthc 2015; 9:319-24. [PMID: 24787558 DOI: 10.1097/sih.0000000000000033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Iatrogenic complications associated with chest tube insertion (CTI) could be related to the gaps in the procedural fidelity of the current CTI training models and their insufficiency to support training of procedural mastery. A CTI bench model simulation developed with reference to preexisting curriculum increases trainees' exposure and practice of this clinical skill. Newly developed training models need to be recognized by trainees as a usable learning device. In this report, we describe the development of a novel CTI model, based on curriculum, and survey its usability as a training model among pediatric trainees. METHODS Based on the acute trauma life support curriculum for CTI and expert interview, a pediatric CTI task trainer (PCTITT) model was developed, piloted, and then implemented for usability by volunteer pediatric residents and pediatric emergency fellows in 2 procedural training courses. Participants responded to 11 questions designed to capture self-reported attitudes toward the usability of the PCTITT as a training model for CTI. Results were obtained using a subjective 5-point Likert scale. RESULTS Of the 32 participants, we achieved a response rate of 75%. Of these respondents, 92% had some kind of CTI hands-on training in the past, and 50% had experience with a real patient. Of these respondents, 91% recommended this model for training, and 80% stated that this model was superior to previous models. CONCLUSIONS A PCTITT is an easy to create and feasible bench top task trainer to teach CTI skills, which integrates with other simulations currently in use the process of teaching CTI. Trainees recognized it as usable and superior to previous models. Future work needs to focus on the improvement of model fidelity, skills transferability, and tool validation.
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Bae JM. Life threatening hemoperitoneum and liver injury as a result of chest tube thoracostomy. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2015; 8:15-7. [PMID: 25780345 PMCID: PMC4345926 DOI: 10.4137/ccrep.s23139] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 01/15/2015] [Accepted: 01/25/2015] [Indexed: 11/08/2022]
Abstract
Common complications of chest tube thoracostomy (CTT) include lung laceration, chest wall bleeding, improper position of tube, subcutaneous emphysema, and so on. Although intra-abdominal injury because of CTT was possible in stomach, spleen, and liver, published reports are rare and no case of life-threatening hemoperitoneum because of CTT has been published in the literature. Here, we present a rare case of life-threatening hemoperitoneum and liver injury because of CTT. We successfully treated the case with emergent laparotomy. Owing to great rarity and particular rare complication of CTT, we report this case with a review of literature.
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Affiliation(s)
- Jung-Min Bae
- Department of Surgery, College of Medicine, Yeungnam University, Daegu, Korea
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13
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Hawley D, Gunn S, Elliott R. The clinical effectiveness of suction versus water seal for optimal management of pleural chest tubes in adult patients: A systematic review protocol. ACTA ACUST UNITED AC 2013. [DOI: 10.11124/jbisrir-2013-989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
This paper describes a previously unreported complication of chest tube thoracostomy: scalpel blade dislodgement within the pleural space. Techniques and complications of chest tube thoracostomy are then discussed.
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Affiliation(s)
- H Poncia
- Royal Sussex County Hospital, Brighton, United Kingdom
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An initial description of a sonographic sign that verifies intrathoracic chest tube placement. Am J Emerg Med 2010; 28:626-30. [PMID: 20579562 DOI: 10.1016/j.ajem.2009.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 03/27/2009] [Accepted: 04/16/2009] [Indexed: 11/20/2022] Open
Abstract
PURPOSE An initial description of a sonographic finding predictive of intrathoracic chest tube placement. METHODS This was a prospective observational study using unembalmed cadaveric models. Chest tubes were randomly placed intra- and extrathoracically and evaluated using ultrasound. Chest tube location was confirmed using blunt dissection followed by tactile and visual confirmation. Sonographers were blinded to chest tube position. Sonographic images obtained in a transverse orientation revealed a subcutaneous hyperechoic arc, created by the chest tube, at the insertion site. The path of the hyperechoic arc was followed cephalad. Disappearance of the hyperechoic arc signified intrathoracic chest tube placement. In contrast, continuation of a subcutaneous hyperechoic arc for the full length of the chest tube signified extrathoracic chest tube placement (the Disappearance/Intrathoracic, Continuation/Extrathoracic sign). RESULTS Ultrasound was used to evaluate 48 chest tube placements. All chest tube locations were identified correctly. In differentiating intra- vs extrathoracic chest tube placement, the Disappearance/Intrathoracic, Continuation/Extrathoracic sign revealed a sensitivity of 100% (95% confidence interval, 83%-100%) and a specificity of 100% (95% confidence interval, 83%-100%). CONCLUSIONS In this small study, bedside ultrasound appears to be highly sensitive and specific in differentiating intra- versus extrathoracic chest tube placement.
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Yoon HY, Mann FA, Lee S, Branson KR. Comparison of the amounts of air leakage into the thoracic cavity associated with four thoracostomy tube placement techniques in canine cadavers. Am J Vet Res 2009; 70:1161-7. [DOI: 10.2460/ajvr.70.9.1161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Small catheter tube thoracostomy: effective in managing chest trauma in stable patients. ACTA ACUST UNITED AC 2009; 66:393-9. [PMID: 19204512 DOI: 10.1097/ta.0b013e318173f81e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. METHODS Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. RESULTS There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. CONCLUSION SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.
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Wakai A, O'Sullivan RG, McCabe G. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev 2007:CD004479. [PMID: 17253510 DOI: 10.1002/14651858.cd004479.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In the management of primary spontaneous pneumothorax, simple aspiration is technically easier to perform. A systematic review may better define the clinical effectiveness and safety of simple aspiration compared to intercostal tube drainage in the management of primary spontaneous pneumothorax. OBJECTIVES To compare the clinically efficacy and safety of simple aspiration and intercostal tube drainage in the management of primary spontaneous pneumothorax. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2006), MEDLINE (1966 to August 2006), and EMBASE (1980 to August 2006). We searched Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (August 2006). We checked the reference lists of trials and contacted trial authors . We imposed no language restriction. SELECTION CRITERIA Randomized controlled trials comparing simple aspiration with intercostal tube drainage in adults aged 18 and over with primary spontaneous pneumothorax. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. No statistical methods were necessary because only one study met the inclusion criteria. MAIN RESULTS Of the 1239 publications obtained from the search strategy, we examined six studies. Five studies were excluded, and one study of 60 participants was eligible for inclusion. There was no difference in immediate success rate of simple aspiration when compared with intercostal tube drainage in the management of primary spontaneous pneumothorax (relative risk (RR) = 0.93; 95% confidence interval (CI) 0.62 to 1.40). There was no significant difference in the early failure rate between the two interventions: RR 1.12 (95% CI 0.59 to 2.13). Simple aspiration reduced the proportion of patients hospitalized (RR = 0.52; 95% CI 0.36 to 0.75). There was no significant difference between the two interventions with regard to the following outcome measures: duration of hospitalization (weighted mean difference = 1.09; 95% CI 2.18 to 0.00); number of participants undergoing any procedure for lung pleurodesis within one year (RR = 0.95; 95% CI 0.41 to 2.22);and one year success rate (RR = 1.02; 95% CI 0.75 to 1.38). AUTHORS' CONCLUSIONS There is no significant difference between simple aspiration and intercostal tube drainage with regard to: immediate success rate, early failure rate, duration of hospitalisation, one year success rate and number of patients requiring pleurodesis at one year. Simple aspiration is associated with a reduction in the per cent of patients hospitalized when compared with intercostal tube drainage.
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Affiliation(s)
- A Wakai
- St Vincent's Hospital, Department of Emergency Medicine, Dublin 4, Ireland.
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21
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Landay M, Oliver Q, Estrera A, Friese R, Boonswang N, DiMaio JM. Lung penetration by thoracostomy tubes: imaging findings on CT. J Thorac Imaging 2007; 21:197-204. [PMID: 16915064 DOI: 10.1097/01.rti.0000213644.57288.2f] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We have analyzed the radiographic and computed tomographic (CT) appearance of thoracostomy (chest) tubes inadvertently placed into the lungs. We have studied the clinical sequela of such malpositioning and discussed treatment options. Cases were collected from chest CT log book reports between January 1998 and January 31, 2005 which indicated or suggested intrapulmonary thoracostomy tube placement. CT scans were reviewed by the authors. The chest radiographs and medical records--including thoracic surgical reports--of those patients whose scans demonstrated intrapulmonary tube placement or indeterminate tube location were reviewed. Fifty patients, in whom 51 thoracostomy tubes were placed into the lungs, are included in this series. None of these tubes were described as intrapulmonary on reports of chest radiographs done before CT scanning. In 13 patients (26%), thoracostomy tube placements produced immediate improvement in pleural abnormalities. Dramatic increase or development of chest wall emphysema or pneumothorax was noted in 4 (8%) patients after tube placement. Twenty-five patients (50%) demonstrated either abrupt or gradual increase in pulmonary or pleural opacity on postplacement chest radiographs. Twenty-one (42%) had no apparent clinical complications. Thirteen (26%) had either prolonged air leaks or recurrent pneumothorax. Ten (20%) developed pneumonia. Retained hemothorax or empyema occurred in 8 (16%). Twelve patients (24%) required subsequent thoracic surgery. Intrapulmonary placement of thoracostomy tubes is probably more common than previously reported. This possibility should be considered when radiographs and CT scans are evaluated.
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Affiliation(s)
- Michael Landay
- Departments of Radiology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-8896, USA.
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22
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Horsley A, Jones L, White J, Henry M. Efficacy and complications of small-bore, wire-guided chest drains. Chest 2007; 130:1857-63. [PMID: 17167009 DOI: 10.1378/chest.130.6.1857] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Small-bore Seldinger-type chest drains have become increasingly popular in recent years, but there are few data on their effectiveness. METHODS Data were collected prospectively at the time of drain insertion and continued until drain removal. Patients completed a visual analog score (VAS) of pain on drain insertion. RESULTS Fifty-two drains were inserted in 44 patients over 10 months. Drain sizes ranged from 12 to 20F. The mean (+/- SEM) patient age was 64 +/- 2 years, and mean duration of drainage was 4.5 +/- 0.5 days. Fourteen drains (27%) were inserted for pneumothoraces, 19 drains (37%) for malignant effusions, 10 drains (19%) for empyema, 5 drains (10%) for parapneumonic effusions, and 4 drains (8%) for other effusions. Pain VAS ranged from 3 to 66 mm (maximum, 100 mm; average [+/- SD], 23 +/- 16 mm). Although the overall drain failure rate was 37%, there was only one serious complication (empyema), and this compares well with historical control subjects. Success rate was highest when used to treat malignant effusions (83%) and pneumothoraces (64%); drains inserted for empyema were more likely to block (overall success rate, 20%). There was no correlation between the type of fluid or size of drain and likelihood of blockage. CONCLUSIONS Seldinger-type drains are a well-tolerated and effective method of draining pneumothoraces and uncomplicated effusions. They are more likely to block when draining empyemas but have a comparable failure rate in pneumothorax to large-bore drains.
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Affiliation(s)
- Alex Horsley
- Molecular Medicine Centre, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK.
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23
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Waydhas C, Sauerland S. Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review. Resuscitation 2006; 72:11-25. [PMID: 17118508 DOI: 10.1016/j.resuscitation.2006.06.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Revised: 06/13/2006] [Accepted: 06/20/2006] [Indexed: 02/01/2023]
Abstract
Pre-hospital insertion of chest tubes or decompression of air within the pleural space is one of the controversial topics in emergency medical care of trauma patients. While a wide variety of opinions exist medical personnel on the scene require guidance in situations when tension pneumothorax or progressive pneumothorax is suspected. To ensure evidence based decisions we performed a systematic review of the current literature with respect to the diagnostic accuracy in the pre-hospital setting to identify patients with (tension) pneumothorax, the efficacy and safety of performing pleural decompression in the field and the choice of method and technique for the procedure. The evidence found is presented and discussed and recommendations are drawn from the authors' perspective.
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Affiliation(s)
- Christian Waydhas
- Department of Trauma Surgery, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany.
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24
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Abstract
Thorax injuries may be divided etiologically into blunt and penetrating types, depending on the nature of the insult. In European practice, the former predominates by far, and in only about 5% of cases thoracotomy provides the necessary thorax drainage. Morbidity in this type of injury typically involves concomitant lung contusion, sometimes with fatal acute respiratory distress syndrome. In these cases, special ventilation forms, optimal reduction of pain, and organ replacement are the decisive therapeutic methods. In contrast, about 80% of penetrating trauma to the thorax require prompt transpleural or trans-sternal surgery, depending on the type of injury. Emergency first aid must follow the principle of "scoop and run". Each minute elapsed until emergent thoracotomy can be decisive to survival in these cases, and the fastest possible transport from the place of injury takes priority over time-consuming stabilization.
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Affiliation(s)
- H Schelzig
- Universitätsklinik für Thorax- und Gefässchirurgie, Universität Ulm.
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25
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Abstract
This review examines the present understanding of tension pneumothorax and produces recommendations for improving the diagnostic and treatment decision process.
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26
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Abstract
The preclinical tension pneumothorax which even without technical support is easily recognizable, requires immediate decompression. However, there are a number of patients with thoracic injuries such as serial rib fractures or palpable skin emphysema which--in combination with a ventilator--may necessitate the insertion of a thoracic tube. In the preclinical setting this procedure usually only takes place in the ventilated patient. With patients who are respiratorily compensated and are breathing spontaneously, careful control and a conservative approach is advised even if pneumothorax is suspected.
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Affiliation(s)
- A Aul
- Abteilung für Anästhesie, Intensivmedizin und Schmerztherapie, BG Unfallklinik, Ludwigshafen/Rh.
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Marshall JC, Maier RV, Jimenez M, Dellinger EP. Source control in the management of severe sepsis and septic shock: An evidence-based review. Crit Care Med 2004; 32:S513-26. [PMID: 15542959 DOI: 10.1097/01.ccm.0000143119.41916.5d] [Citation(s) in RCA: 152] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for source control in the management of severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSION Source control represents a key component of success in therapy of sepsis. It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function. Although highly logical, since source control is the best way to reduce quickly the bacterial inoculum, most recommendations are, however, graded as D or E due to the difficulty to perform appropriate randomized clinical trials in this respect. Appropriate source control should be part of the systematic checklist we have to keep in mind in setting up the therapeutic strategy in sepsis.
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Affiliation(s)
- John C Marshall
- From the Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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28
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Affiliation(s)
- M Henry
- Department of Respiratory Medicine, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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29
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Affiliation(s)
- M Henry
- Department of Respiratory Medicine, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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30
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Tang ATM, Velissaris TJ, Weeden DF. An evidence-based approach to drainage of the pleural cavity: evaluation of best practice. J Eval Clin Pract 2002; 8:333-40. [PMID: 12164980 DOI: 10.1046/j.1365-2753.2002.00339.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent surveys have uncovered major variations in key aspects of intercostal drain management, suggesting that decisions are being made on individual preferences without resorting to sound evidence. We provide an up-to-date review of the best practice with evidence-based recommendations and expert consensus views. The following aspects of chest drain management have been addressed: indications for drainage, insertion technique, complications, management of an indwelling chest drain, indications and technique for removal. The emphasis in this review is that safe intercostal drain practice relies upon adherence to a few important principles. Furthermore, when in doubt, particularly with a complex thoracic problem, one should seek prompt specialist advice.
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Affiliation(s)
- Augustine T M Tang
- Department of Thoracic Surgery, Wessex Regional Cardiac and Thoracic Unit, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK.
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31
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32
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Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R. Chest tube removal: end-inspiration or end-expiration? THE JOURNAL OF TRAUMA 2001; 50:674-7. [PMID: 11303163 DOI: 10.1097/00005373-200104000-00013] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recurrent pneumothorax is the most significant complication after discontinuation of thoracostomy tubes. The primary objective of the present study was to determine which method of tube removal, at the end of inspiration or at the end of expiration, is associated with a lesser risk of developing a recurrent pneumothorax. A secondary objective was to identify potential risk factors for developing recurrence. METHODS A prospective study of 102 chest tubes in 69 trauma patients (1.5 tubes per patient) randomly assigned to removal at the end of inspiration (n = 52) or the end of expiration (n = 50). RESULTS Recurrent pneumothorax or enlargement of a small but stable pneumothorax was observed after the removal of four chest tubes in the end-inspiration group (8%) and after discontinuation of three chest tubes (6%) in the end-expiration group (p = 1.0). Of those, only two tubes in the end-inspiration group and 1 tube in the end-expiration group required repeat closed thoracostomy. Multiple factors were analyzed that did not adversely affect outcome. These included patient age, Injury Severity Score, Revised Trauma Score, mechanism of injury, hemothorax, thoracotomy, thoracostomy, previous lung disease, chest tube duration, the presence of more than one thoracostomy tube in the same hemithorax, or a small (but stable) pneumothorax at the time of tube removal. CONCLUSIONS Discontinuation of chest tubes at the end of inspiration or at the end of expiration has a similar rate of post-removal pneumothorax. Both methods are equally safe.
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Affiliation(s)
- R L Bell
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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33
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Single-Trocar-Access Thoracoscopy For Fully Optical Controlled Routine Chest Drainage: A Technical Report and Feasibility Study. Surg Laparosc Endosc Percutan Tech 2000. [DOI: 10.1097/00129689-200012000-00010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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Perez L, Klofas E. Unrecognized right endobronchial intubation causing total left lung collapse in a pediatric trauma patient. Am J Emerg Med 2000; 18:355-6. [PMID: 10830708 DOI: 10.1016/s0735-6757(00)90146-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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36
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Jantz MA, Sahn SA. Pleural Disease in the Intensive Care Unit. J Intensive Care Med 2000. [DOI: 10.1046/j.1525-1489.2000.00063.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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37
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Jantz MA, Sahn SA. Pleural Disease in the Intensive Care Unit. J Intensive Care Med 2000. [DOI: 10.1177/088506660001500201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.
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Affiliation(s)
- Michael A. Jantz
- From the Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC
| | - Steven A. Sahn
- From the Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC
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38
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Abstract
This study compared the complication rates of tube thoracostomy performed in the emergency department (ED) versus the operating room (OR) and the inpatient ward (IW). A retrospective case series of all patients at an urban, university-based level 1 trauma center hospital who received tube thoracostomy for any indication between 1/1/93 and 12/31/93 was conducted. Complications were defined as empyema, unresolved pneumothorax (persistent air leak or residual pneumothorax), persistent effusion, or incorrect placement. The data for age and duration of tube placement were weighted for analysis of variance (ANOVA). A total of 352 tube thoracostomies was placed in 239 patients. Twenty-three patients had three or more chest tubes placed, 65 had two placed, and the remaining 181 had a single tube. Ninety-nine tubes were placed in the ED, 87 in the OR, and 166 on IW. The mean age of patients in the ED was 37 years, and differed significantly (P < .015) from those in the OR (48 years) and the IW (44 years). The duration of tube placement was similar for all groups (mean = 6.5 days). The overall complication rates related to tube insertion were: ED, 14.0%; OR, 9.2%; IW, 25.3%. Significance was achieved when comparing complication rates between the ED and IW, with less complications in the ED (P = .0436). When comparing complication rates between the ED and OR, there was no significant difference (P = .3643). A power calculation indicated too small of a sample size to truly determine an insignificant difference between complication rates between the ED and OR. Placement of emergent thoracostomy tubes in the ED does not result in an increased complication rate as compared to placement in the IW.
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Affiliation(s)
- L Chan
- Department of Emergency Medicine, Albany Medical Center, NY 12208, USA
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39
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Abstract
This article provides an overview of the multitude of medical devices used in patients from head to toe. Simple line drawings show a wide assortment of medical devices. These drawings and the accompanying short descriptions are to be used for quick reference to identify some of the more common medical devices that are certain to appear on everyday radiographs. There is an extensive bibliography for the reader to obtain more detailed information about a particular device or medical apparatus. Knowing the specific name of a device is nearly impossible and is really not necessary, in particular, the eponyms attached to all manner of orthopedic apparatus. Many device names have evolved from their original meaning. What is important is the device's function and the recognition of its presence, as well as an understanding of its use and potential complications.
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Affiliation(s)
- T B Hunter
- Department of Radiology, College of Medicine, University of Arizona, Tucson, USA
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Abstract
OBJECTIVE To examine the management of traumatic pneumothorax in a department where some of these injuries do not receive chest drains. METHODS A retrospective study of the management of traumatic pneumothorax was performed on a unit where historically many of these injuries have been treated conservatively. RESULTS 54 pneumothoraces in a three year period were identified. Of these, 29 injuries (54.7%) were initially managed without drainage. Two patients subsequently had chest drains inserted as a result of asymptomatic radiological enlargement of the pneumothorax while inpatients. No patients deteriorated clinically during conservative treatment. CONCLUSIONS Chest drain insertion for small or moderate sized traumatic pneumothoraces, in the absence of other significant injuries or the need for intermittent positive pressure ventilation (IPPV), may be unnecessary.
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Affiliation(s)
- G Johnson
- Accident and Emergency Department, Derriford Hospital, Plymouth
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41
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Abstract
The physiological variables of oxygen saturation, blood pressure and pulse rate were compared in the pre-hospital phase and on arrival at hospital in a group of 63 patients with severe chest injury. Eighty-nine pre-hospital thoracic drainage procedures were carried out. Pre-hospital Advanced Trauma Life Support (ATLS) was associated with a significant improvement in all three variables. Median oxygen saturation increased by 17 per cent (P < 0.001), median blood pressure increased from 90 to 120 mmHg (P < 0.001) and median pulse rate decreased from 125 to 105 (P < 0.001). Pre-hospital intervention is indicated for tension pneumothorax, and contraindicated for haemothorax without respiratory compromise. In other situations further evidence is required, and standard ATLS protocols should be used until this is available.
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Affiliation(s)
- T J Coats
- Helicopter Emergency Medical Service, Royal London Hospital, UK
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Barton ED, Epperson M, Hoyt DB, Fortlage D, Rosen P. Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews. J Emerg Med 1995; 13:155-63. [PMID: 7775785 DOI: 10.1016/0736-4679(94)00135-9] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The use of prehospital tube thoracostomy (TT) for the treatment of suspected tension pneumothorax (TPtx) in trauma patients is controversial. A study is presented that reviews a 6-year experience with the use of needle catheter aspiration (NA) and chest tubes performed in the field by air medical personnel. Prehospital flight charts and hospital records from 207 trauma patients who underwent one or both of these procedures in the field were retrospectively reviewed. The clinical indications used to determine treatment are presented for both procedures. Improvement in clinical status of patients observed by flight personnel were similar for both treatment groups (54% for NA, 61% for TT). Thirty-two (38%) of the TT patients had failed NA attempts prior to chest tube placement. Average time on scene (T.O.S.) was significantly greater for the TT group (25.7 min versus 20.3 min for NA group). Fewer patients were pronounced dead on arrival (D.O.A.) with TT treatment compared to NA alone (7% versus 19%, respectively). Injury severity scores, number of hospital complications, length of stay (L.O.S.), and total hospital costs were not different between the two groups. There were no cases of lung damage or empyema formation associated with prehospital TT treatment. Overall mortality was similar for both groups. From these data, we conclude that NA is a relatively rapid intervention in the treatment of suspected TPtx in the prehospital setting; however, TT is an effective adjunct for definitive care without increasing morbidity or mortality. A better understanding of the physiology of intrapleural air masses is needed to determine the most effective decompression requirements prior to aeromedical transport.
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Affiliation(s)
- E D Barton
- Department of Emergency Medicine, University of California, San Diego Medical Center 92013-8676, USA
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York D, Dudek L, Larson R, Marshall W, Dries D. A comparison study of chest tube thoracostomy: air medical crew and in-hospital trauma service. Air Med J 1993; 12:227-9. [PMID: 10128291 DOI: 10.1016/s1067-991x(05)80187-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chest tube thoracostomy (CTT) is not frequently performed by non-physician-staffed air medical crews (AMC) due to concern regarding safety, efficiency and training requirements. This study compared two groups of patients requiring CTT, one group with insertion performed by an AMC and the other by a physician trauma service (TS) in the emergency department on patient arrival. The CTT of 172 patients managed at a Level I trauma center between October 1988 and September 1990 were reviewed. Seventy-two patients were managed by the AMC and received CTT in a prehospital setting; the air medical personnel placed the chest tube cleanly in all cases. Chest tubes placed by AMC were removed within 48 hours of transport to minimize infection risk. One hundred patients requiring CTT in the hospital setting were randomly selected from the trauma registry during a similar time span. The study compared the patients' Injury Severity Scores (ISS), and trauma scores, any placement complications and the overall mortality. While the AMC often treated patients with higher acuity, as reflected by ISS and trauma scores and overall higher mortality, the rate of complications between CTT performed by AMC and TS was similar. Appropriately trained AMC can safely perform CTT without putting patients at increased risk.
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Affiliation(s)
- D York
- Loyola University Medical Center, Maywood, IL
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Abstract
Tube thoracostomy is a standard therapy for a number of pulmonary disorders. The procedure is associated with a certain incidence of morbidity related to the technique of insertion, the patient population selected, and the length of time the tube remains in place. Complications of tube placement previously described include empyema, residual pneumothorax, lung perforation, placement of the tube in the chest wall, diaphragmatic perforation, perforation of intraabdominal organs (such as spleen, liver and stomach), unilateral pulmonary edema, bronchopleural fistula, hemothorax, cardiogenic shock and Horner syndrome. A case of a delayed pulmonary perforation developing several days after placement of a chest tube is described with a discussion of the clinical and radiographic findings associated with this complication. A possible pathophysiologic mechanism by which this complication may have occurred is proposed.
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Affiliation(s)
- D K Resnick
- Department of Surgery, Pennsylvania Hospital, Philadelphia
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47
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Abstract
The stomach, located in the intrathoracic portion of the abdomen, is well protected from injury. It has a thick wall that is easily mobilized and a rich blood supply that ensures rapid healing of wounds. Although the gastric contents may be contaminated by oral flora immediately after meals, in the resting state, the stomach has few, if any, endogenous organisms. All of these factors make morbidity and mortality associated with penetrating injuries low. In contrast, blunt injuries often cause extensive contamination of the peritoneal cavity with resultant high morbidity and mortality.
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Affiliation(s)
- R Durham
- Department of Surgery, St. Louis University Medical Center, Missouri
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48
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Eddy AC, Luna GK, Copass M. Empyema thoracis in patients undergoing emergent closed tube thoracostomy for thoracic trauma. Am J Surg 1989; 157:494-7. [PMID: 2712206 DOI: 10.1016/0002-9610(89)90643-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The vast majority of thoracic trauma victims require only observation or tube thoracostomy for definitive treatment of their thoracic injury. Although tube thoracostomy is generally considered a limited intervention, 2 to 25 percent of patients who undergo this procedure develop infectious complications. To determine the incidence and risk factors for the development of empyema thoracis after tube thoracostomy, a retrospective study was undertaken. We found that the development of empyema thoracis was increased in patients whose pleural space was incompletely drained and whose thoracic catheters were in place for a prolonged period.
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Affiliation(s)
- A C Eddy
- Department of Surgery, School of Medicine, University of Washington, Seattle 98194
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49
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Affiliation(s)
- D J Muckart
- Department of Surgery, University of Natal, Durban, South Africa
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50
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Hirshberg A, Thomson SR, Bade PG, Huizinga WK. Pitfalls in the management of penetrating chest trauma. Am J Surg 1989; 157:372-5; discussion 376. [PMID: 2929860 DOI: 10.1016/0002-9610(89)90577-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A prospective study designed specifically to analyze errors in management and iatrogenic complications was conducted on 234 consecutive patients with penetrating chest trauma. Eleven percent of penetrating pleural injuries were incorrectly diagnosed on initial physical and radiologic examination, but this led to wrong management decisions in only 4 percent. Decisions regarding intercostal tube drainage were particularly inaccurate when emergency intubation was required prior to chest radiography. Atypical clinical features of penetrating cardiac injuries caused delay in diagnosis and thoracotomy in 3 of 14 patients. Only two of four mediastinal vascular injuries were recognized on initial examination. Transdiaphragmatic injuries were initially missed in 5 of 14 patients. This resulted in management errors and delay in these patients. Awareness of atypical presentations and circumstances in which misjudgments and wrong decisions are prone to occur should help to avoid pitfalls and reduce mortality from penetrating chest trauma.
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Affiliation(s)
- A Hirshberg
- Department of Surgery, University of Natal Medical School, Durban, South Africa
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