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Takeda K, Kasai H, Shimizu I, Hirama R, Hayama N, Shikano K, Abe M, Naito A, Suzuki T. Complications Rate and a Multidimensional Analysis of Their Causes of Tube Thoracostomy: A Mixed-Methods Study. Cureus 2024; 16:e58563. [PMID: 38765428 PMCID: PMC11102531 DOI: 10.7759/cureus.58563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Tube thoracostomy (TT) complications are common in respiratory medicine. However, the prevalence of complications and risk factors is unknown, and data on countermeasures are lacking. METHODS This was a mixed-methods retrospective observational and qualitative study. This retrospective observational study included TT performed on patients admitted to the Department of Respiratory Medicine at our University Hospital between January 1, 2019, and August 31, 2022 (n=169). The primary endpoint was the incidence of TT-related complications. We reviewed the association between complications and patient- and medical-related factors as secondary endpoints. In this qualitative study, we theorized the background of physicians' susceptibility to TT-related complications based on the grounded theory approach. RESULTS Complications were observed in 20 (11.8%) of the 169 procedures; however, they were unrelated to 30-day mortality. Poor activities of daily living (odds ratio 4.3, p=0.007) and regular administration of oral steroids (odds ratio 3.1, p=0.025) were identified as patient-related risk factors. Physicians undergoing training caused the most complications, and the absence of a senior physician at the procedure site (odds ratio 3.5, p=0.031) was identified as a medical risk factor. Based on this qualitative study, we developed a new model for TT complication rates consistent with the relationship between physicians' professional skills, professional identity, and work environments. CONCLUSIONS Complications associated with TT are common. Therefore, it is necessary to implement measures similar to those identified in this study. Particularly, a supportive environment should be established for the training of physicians.
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Affiliation(s)
- Kenichiro Takeda
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Hajime Kasai
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
- Department of Medical Education, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Ikuo Shimizu
- Department of Medical Education, Chiba University Graduate School of Medicine, Chiba, JPN
- Department of Quality and Patient Safety, Chiba University Hospital, Chiba, JPN
| | - Ryutaro Hirama
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Nami Hayama
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Kohei Shikano
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Mitsuhiro Abe
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Akira Naito
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Takuji Suzuki
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, JPN
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Parikh S, Howell M, Yeh HW, Cheruvu M, Goodwin R, Shellenberger J. A Retrospective Analysis of Needle Thoracostomies at a Tertiary Level 2 Trauma Center. Cureus 2024; 16:e55736. [PMID: 38586656 PMCID: PMC10998708 DOI: 10.7759/cureus.55736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND A tension pneumothorax is a condition that results in elevated pressure within the pleural space. The effective management of tension pneumothorax relies on needle decompression, commonly performed at the second intercostal space (ICS) midclavicular line (MCL). However, some literature suggests that catheters placed in the second intercostal space midclavicular line are prone to higher failure rates compared to the fifth intercostal space midaxillary line (MAL) (42.5% versus 16.7%, respectively). In this study, we aim to identify and scrutinize the prevalence of prehospital needle decompression from one tertiary care center over eight years and examine their trends, efficacies, or pitfalls. It is hypothesized that preclinical providers are performing needle decompression prematurely and unnecessarily. METHODS A set of 90 patient records obtained using the trauma registry at Saint Francis Hospital, Tulsa, Oklahoma, were retrospectively reviewed to evaluate the management and outcomes of tension pneumothorax, as well as the indications documented for needle decompression. Patient charts were reviewed via Epic Hyperspace (Epic, Madison, WI). The Oklahoma Emergency Medical Service Information System (OKEMSIS) also provided information contributing to the sample population. RESULTS The most documented indications for needle decompressions included diminished or absent breath sounds (52.70%), hypoxia (15.54%), hypotension, and hemodynamic instability (6.76%). Emergency medical services (EMS) reported improvements in 51 (56.67%) patients after needle thoracostomy. Improvements in vital signs after needle decompression were sporadic. The most common complication was catheter dislodging, which occurred most in the second intercostal space midclavicular line. Only nine patients had an oxygen saturation (SpO2) below 92% and a systolic blood pressure (SBP) below 100 mm Hg prior to receiving needle decompression. CONCLUSION Current practices for tension pneumothorax show little improvement in vital signs before and after needle decompression. Vital signs prior to needle decompression often do not indicate tension pneumothorax physiology. Preclinical providers may be inappropriately performing needle decompressions, an invasive procedure with complications.
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Affiliation(s)
- Sarthak Parikh
- Trauma Institute, Saint Francis Health System, Tulsa, USA
- Department of Orthopedic Surgery, Oklahoma State University, Tulsa, USA
- Center for Clinical Research and Sponsored Programs, Saint Francis Health System, Tulsa, USA
| | | | - Hung-Wen Yeh
- Division of Health Services and Outcomes Research, University of Missouri-Kansas City School of Medicine, Kansas City, USA
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, USA
| | - Mani Cheruvu
- Center for Clinical Research and Sponsored Programs, Saint Francis Health System, Tulsa, USA
| | - Robert Goodwin
- Trauma Institute, Saint Francis Health System, Tulsa, USA
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Garner A, Poynter E, Parsell R, Weatherall A, Morgan M, Lee A. Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults. Eur J Trauma Emerg Surg 2023; 49:571-581. [PMID: 35881149 DOI: 10.1007/s00068-022-02049-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/30/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy. METHODS In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique. RESULTS Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85). CONCLUSIONS There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.
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Affiliation(s)
- Alan Garner
- Nepean Clinical School, Trauma Services, Nepean Hospital, University of Sydney, Derby Street, Kingswood, NSW, 2747, Australia.
| | - Elwyn Poynter
- Research Nurse, CareFlight Australia, Sydney, Australia
| | - Ruth Parsell
- CareFlight Rapid Response Helicopter, Sydney, Australia
| | - Andrew Weatherall
- CareFlight Australia, Division of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Mary Morgan
- Hunter Retrieval Service, John Hunter Hospital, Newcastle, NSW, Australia
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
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Kushida Y, Takeuchi I, Muramatsu KI, Nagasawa H, Jitsuiki K, Ohsaka H, Ishikawa K, Yanagawa Y. A Comparison of Tube Thoracostomy for Chest Trauma Between Prehospital and Inhospital Settings. Air Med J 2023; 42:24-27. [PMID: 36710031 DOI: 10.1016/j.amj.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/19/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We compared the outcomes of patients with tube thoracostomy for chest trauma between the prehospital and inhospital settings. METHODS The subjects were then divided into 2 groups: the prehospital group, which included subjects who underwent tube thoracostomy in the prehospital setting, and the inhospital group, which included subjects who underwent tube thoracostomy in the inhospital setting. The variables were compared between the 2 groups. RESULTS There were no significant differences between the 2 groups with regard to gender, age, history, mechanism of injury, infusion of antibiotics, white blood cell count, duration of insertion of a chest drain, mechanical ventilation, complication of drain infection, duration of admission, or final outcome. However, the Injury Severity Score, maximum C-reactive protein level, and maximum temperature during hospitalization in the prehospital group (n = 15) were significantly greater than those in the inhospital group (n = 119). CONCLUSION The present study suggested that thoracostomy performed by physicians in the prehospital setting was safe and did not have an increased risk of infection. In addition, thoracostomy for chest injury in the prehospital setting suggested an improvement in the likelihood of a survival outcome.
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Affiliation(s)
- Yoshihiro Kushida
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni City, Shizuoka, Japan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni City, Shizuoka, Japan
| | - Ken-Ichi Muramatsu
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni City, Shizuoka, Japan
| | - Hiroki Nagasawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni City, Shizuoka, Japan
| | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni City, Shizuoka, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni City, Shizuoka, Japan
| | - Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni City, Shizuoka, Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni City, Shizuoka, Japan.
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Merelman A, Zink N, Fisher AD, Lauria M, Braude D. FINGER: A Novel Approach to Teaching Simple Thoracostomy. Air Med J 2022; 41:526-529. [PMID: 36494167 DOI: 10.1016/j.amj.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 12/14/2022]
Abstract
For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax.
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Affiliation(s)
- Andrew Merelman
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
| | | | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM; Texas Army National Guard, Austin, TX
| | - Michael Lauria
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Lifeguard Emergency and Critical Care Transport, Albuquerque, NM
| | - Darren Braude
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Lifeguard Emergency and Critical Care Transport, Albuquerque, NM
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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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Strauss R, Menchetti I, Perrier L, Blondal E, Peng H, Sullivan-Kwantes W, Tien H, Nathens A, Beckett A, Callum J, da Luz LT. Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research. Trauma Surg Acute Care Open 2021; 6:e000773. [PMID: 34746434 PMCID: PMC8527149 DOI: 10.1136/tsaco-2021-000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/27/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools. RESULTS Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2). CONCLUSIONS The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Rachel Strauss
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Isabella Menchetti
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laure Perrier
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erik Blondal
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Henry Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Wendy Sullivan-Kwantes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Homer Tien
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Luis Teodoro da Luz
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Abstract
INTRODUCTION Pneumothorax remains an important cause of preventable trauma death. The aim of this systematic review is to synthesize the recent evidence on the efficacy, patient outcomes, and adverse events of different chest decompression approaches relevant to the out-of-hospital setting. METHODS A comprehensive literature search was performed using five databases (from January 1, 2014 through June 15, 2020). To be considered eligible, studies required to report original data on decompression of suspected or proven traumatic pneumothorax and be considered relevant to the prehospital context. They also required to be conducted mostly on an adult population (expected more than ≥80% of the population ≥16 years old) of patients. Needle chest decompression (NCD), finger thoracostomy (FT), and tube thoracostomy were considered. No meta-analysis was performed. Level of evidence was assigned using the Harbour and Miller system. RESULTS A total of 1,420 citations were obtained by the search strategy, of which 20 studies were included. Overall, the level of evidence was low. Eleven studies reported on the efficacy and patient outcomes following chest decompression. The most studied technique was NCD (n = 7), followed by FT (n = 5). Definitions of a successful chest decompression were heterogeneous. Subjective improvement following NCD ranged between 18% and 86% (n = 6). Successful FT was reported for between 9.7% and 32.0% of interventions following a traumatic cardiac arrest. Adverse events were infrequently reported. Nine studies presented only on anatomical measures with predicted failure and success. The mean anterior chest wall thickness (CWT) was larger than the lateral CWT in all studies except one. The predicted success rate of NCD ranged between 90% and 100% when using needle >7cm (n = 7) both for the lateral and anterior approaches. The reported risk of iatrogenic injuries was higher for the lateral approach, mostly on the left side because of the proximity with the heart. CONCLUSIONS Based on observational studies with a low level of evidence, prehospital NCD should be performed using a needle >7cm length with either a lateral or anterior approach. While FT is an interesting diagnostic and therapeutic approach, evidence on the success rates and complications is limited. High-quality studies are required to determine the optimal chest decompression approach applicable in the out-of-hospital setting.
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De La Hoz Polo M, Sandhu A, Kashef E, Aylwin C, Bew D, Manikon M, Dick E. Medical and surgical devices in the emergency and trauma patient: what the radiologist should know, and how they can add value. Br J Radiol 2021; 94:20200530. [PMID: 33095656 DOI: 10.1259/bjr.20200530] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A variety of different external and internal medical devices are used in the acute setting to maintain life support and manage severely injured and unstable trauma or emergency patients. These devices are inserted into the acutely ill patient with the specific purpose of improving outcome, but misplacement can cause additional morbidity and mortality. Consequently, meaningful interpretation of the position of devices can affect acute management. Some devices such as nasopharyngeal, nasogastric and endotracheal tubes and chest and surgical drains are well known to most clinicians, however, little formal training exists for radiologists in composing their report on the imaging of these devices. The novice radiologist often relies on tips and phrases handed down in an aural tradition or resorts to phrases such as: "position as shown". Furthermore, radiologists with limited experience in trauma might not be familiar with the radiological appearance of other more specific devices. This review will focus on the most common medical devices used in acute trauma patients, indications, radiological appearance and their correct and suboptimal positioning.
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Affiliation(s)
| | - Amandeep Sandhu
- Radiology Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Elika Kashef
- Interventional and Trauma Radiology Department, Clinical Lead for Interventional and Trauma Radiology, Imperial College Healthcare NHS Trust, London, UK
| | - Christopher Aylwin
- Vascular & Trauma Surgery Department,Head of Specialty Major Trauma, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Duncan Bew
- Major Trauma and Surgery Department, Clinical Director of Major Trauma and Surgery, King´s College Hospital NHS Foundation Trust, London, UK
| | - Maribel Manikon
- Intensive Care Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Elizabeth Dick
- Radiology Department, Lead for Emergency Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Bar A, Lin G, Lazar LO, Blanka-Deak J, Khalayleh H, Pines G. Immediate Pneumothorax Diagnosis by Surgical Residents Using Portable Ultrasound. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:152-156. [PMID: 33448887 DOI: 10.1177/1556984520978315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Feasibility of diagnosis of pneumothorax using handheld ultrasound by non-radiologists shows inconsistent results. The aim of this study is to evaluate the feasibility and accuracy of portable ultrasound for immediate diagnosis of pneumothorax by general surgery residents who underwent short training. METHODS Patients who presented to the emergency department of a university hospital with suspected pneumothorax between 10/2018 and 12/2019 were included in the study. Patients underwent ultrasound in 2 points of each hemithorax. Sensitivity and specificity for pneumothorax diagnosis by ultrasound and physical examination were calculated and compared with chest computed tomography (CT). Patients in whom a chest tube was placed prior to ultrasound examination and those who did not undergo a CT scan were excluded from the study. RESULTS A total of 85 patients met the inclusion criteria. Mean age was 40.7 ± 20.2 years. Pneumothorax was found among 46 patients (54%) per chest CT, and of these, 21 (46%) underwent chest tube placement following imaging. Ultrasound showed the highest sensitivity and specificity (95.6% [95% confidence interval {CI} 85.16% to 99.47%] and 97.44% [95% CI 86.40% to 99.67%], respectively). Chest x-ray had the lowest sensitivity (47.8% [95% CI 32.89% to 63.05%]) for pneumothorax detection. Physical examination showed a moderate sensitivity and specificity (82.6% [95% CI 68.58% to 92.18%] and 77.89% [95% CI 60.67% to 88.87%], respectively) for the diagnosis of pneumothorax. CONCLUSIONS We found high accuracy rates of 2-point ultrasound in immediate pneumothorax diagnosis when performed by surgical residents who underwent a short ultrasound training. This is a fast and repeatable test, and has the potential for successful implementation in prehospital and military scenarios as well, minimizing unnecessary chest tube placements.
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Affiliation(s)
- Alon Bar
- 37601 Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University Medical School, Jerusalem, Israel
| | - Guy Lin
- 37601 Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University Medical School, Jerusalem, Israel
| | - Li Or Lazar
- 37601 Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University Medical School, Jerusalem, Israel.,37601 Department of Thoracic Surgery, Kaplan Medical Center, Rehovot and The Hebrew University Medical School, Jerusalem, Israel
| | - Judit Blanka-Deak
- 37601 Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University Medical School, Jerusalem, Israel
| | - Harbi Khalayleh
- 37601 Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University Medical School, Jerusalem, Israel
| | - Guy Pines
- 37601 Department of Surgery, Kaplan Medical Center, Rehovot and The Hebrew University Medical School, Jerusalem, Israel.,37601 Department of Thoracic Surgery, Kaplan Medical Center, Rehovot and The Hebrew University Medical School, Jerusalem, Israel
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11
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Hannon L, St Clair T, Smith K, Fitzgerald M, Mitra B, Olaussen A, Moloney J, Braitberg G, Judson R, Teague W, Quinn N, Kim Y, Bernard S. Finger thoracostomy in patients with chest trauma performed by paramedics on a helicopter emergency medical service. Emerg Med Australas 2020; 32:650-656. [PMID: 32564497 DOI: 10.1111/1742-6723.13549] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 04/08/2020] [Accepted: 04/27/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine the frequency of finger thoracostomy performed by intensive care flight paramedics after the introduction of a training programme in this procedure and complications of the procedure that were diagnosed after hospital arrival. METHODS This was a retrospective cohort study of adult and paediatric trauma patients undergoing finger thoracostomy performed by paramedics on a helicopter emergency medical service between June 2015 and May 2018. Hospital data were obtained through a manual search of the medical records at each of the three receiving major trauma services. Additional data were sourced from the Victorian State Trauma Registry. RESULTS The final analysis included 103 cases, of which 73.8% underwent bilateral procedures with a total of 179 finger thoracostomies performed. The mean age of patients was 42.8 (standard deviation 21.4) years and 73.8% were male. Motor vehicle collision was the most common mechanism of injury accounting for 54.4% of cases. The median Injury Severity Score was 41 (interquartile range 29-54). There were 30 patients who died pre-hospital, with most (n = 25) having finger thoracostomy performed in the setting of a traumatic cardiac arrest. A supine chest X-ray was performed prior to intercostal catheter insertion in 38 of 73 patients arriving at hospital; of these, none demonstrated a tension pneumothorax. There were three cases of potential complications related to the finger thoracostomy. CONCLUSION Finger thoracostomy was frequently performed by intensive care flight paramedics. It was associated with a low rate of major complications and given the deficiencies of needle thoracostomy, should be the preferred approach for chest decompression.
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Affiliation(s)
- Liam Hannon
- Ambulance Victoria, Melbourne, Victoria, Australia.,Emergency Department, Bendigo Health, Bendigo, Victoria, Australia
| | - Toby St Clair
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Trauma, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Ambulance Victoria, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - John Moloney
- Ambulance Victoria, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia
| | - George Braitberg
- Ambulance Victoria, Melbourne, Victoria, Australia.,Emergency Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rodney Judson
- Emergency Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Warwick Teague
- Department of Trauma, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nuala Quinn
- Department of Trauma, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Yesul Kim
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia
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12
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Falslev C, Thompson SN, Feldhausen D. Novel tube thoracostomy device reduces incision length. Am J Emerg Med 2020; 38:1693-1694. [PMID: 31983597 DOI: 10.1016/j.ajem.2020.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Christopher Falslev
- Boonshaft School of Medicine, Wright State University, 4301 Jones Bridge Road, Washington Township, OH 45459, United States of America.
| | - Shannon N Thompson
- San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States of America
| | - Daniela Feldhausen
- Emergency Medicine PA-C, DSc, Joint Base Elmendorf-Richardson, AK 99506, United States of America
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13
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Ziapour B, Mostafidi E, Sadeghi-Bazargani H, Kabir A, Okereke I. Timing to perform VATS for traumatic-retained hemothorax (a systematic review and meta-analysis). Eur J Trauma Emerg Surg 2019; 46:337-346. [PMID: 31848631 DOI: 10.1007/s00068-019-01275-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/17/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE In this systematic review, we analyzed the optimal time range to evacuate traumatic-retained hemothorax using video-assisted thoracoscopic surgery (VATS). METHODS We searched PubMed, EMBASE, the Cochrane Register of Controlled Trials, Google Scholar, and the U.S. National Library of Medicine clinical trials database up to February 2019. Randomized controlled trials (RCTs) and observational studies with relevant data were included. Data were extracted from studies that reported the success, mortality, or length of hospital stay (LOS) after using VATS during at least two out of three of our time-ranges of interest: days 1-3 (group A), days 4-6 (group B), and day 7 or later (group C). RESULTS Six cohort studies with 476 total participants were included in the meta-analysis. The patients in group A had a significantly higher success rate than those in group C (RR = 0.42; 95% CI = 0.21-0.84, p = 0.01). The total LOS for patients whose retained hemothorax was evacuated in group A was 4.7 days shorter than that for those in group B (95% CI = - 5.6 to - 3.8, p = 0.006). Likewise, group B patients were discharged 18.1 days earlier than group C patients (95% CI = - 22.3 to - 14, p < 0.001). Short-term mortality was not decreased by early VATS. CONCLUSIONS Our results indicate that VATS should be considered within the first three days of admission if this intervention is the clinician's choice to evacuate a traumatic-retained hemothorax. Protocol registration number in PROSPERO: CRD42017046856.
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Affiliation(s)
- Behrad Ziapour
- Tufts Medical Center, 800 Washington Street #1035, Boston, MA, 02111, USA.
| | | | - Homayoun Sadeghi-Bazargani
- Department of Statistics and Epidemiology, School of Health, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ikenna Okereke
- Chief of Thoracic Surgery, Division of Cardiovascular and Thoracic Surgery, Program Director, Cardiothoracic Fellowship Program, Division of Cardiothoracic Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555-0528, USA
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14
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Leonhard G, Overhoff D, Wessel L, Viergutz T, Rudolph M, Schöler M, Haubenreisser H, Terboven T. Determining optimal needle size for decompression of tension pneumothorax in children - a CT-based study. Scand J Trauma Resusc Emerg Med 2019; 27:90. [PMID: 31604472 PMCID: PMC6788035 DOI: 10.1186/s13049-019-0671-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background For neonates and children requiring decompression of tension pneumothorax, specific recommendations for the choice of needle type and size are missing. The aim of this retrospective study was to determine optimal length and diameter of needles for decompression of tension pneumothorax in paediatric patients. Methods Utilizing computed tomography, we determined optimal length and diameter of needles to enable successful decompression and at the same time minimize risk of injury to intrathoracic structures and the intercostal vessels and nerve. Preexisting computed tomography scans of the chest were reviewed in children aged 0, 5 and 10 years. Chest wall thickness and width of the intercostal space were measured at the 4th intercostal space at the anterior axillary line (AAL) on both sides of the thorax. In each age group, three needles different in bore and length were evaluated regarding sufficient length for decompression and risk of injury to intrathoracic organs and the intercostal vessels and nerve. Results 197 CT-scans were reviewed, of which 58 were excluded, resulting in a study population of 139 children and 278 measurements. Width of the intercostal space was small at 4th ICS AAL (0 years: 0.44 ± 0.13 cm; 5 years: 0.78 ± 0.22 cm; 10 years: 1.12 ± 0.36 cm). The ratio of decompression failure to risk of injury at 4th ICS AAL was most favourable for a 22G/2.5 cm catheter in infants (Decompression failure: right: 2%, left: 4%, Risk of injury: right: 14%, left: 24%), a 22G/2.5 cm or a 20G/3.2 cm catheter in 5-year-old children (20G/3.2 cm: Decompression failure: right: 2.1%, left: 0%, Risk of injury: right: 2.1%, left: 17%) and a 18G/4.5 cm needle in 10-year-old children (Decompression failure: right: 9.5%, left: 9.5%, Risk of injury: right: 7.1%, left: 11.9%). Conclusions In children aged 0, 5 and 10 years presenting with a tension pneumothorax, we recommend 22G/2.5 cm, 20G/3.2 cm and 18G/4.5 cm needles, respectively, for acute decompression.
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Affiliation(s)
- Georg Leonhard
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Daniel Overhoff
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Lucas Wessel
- Department of Paediatric Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Tim Viergutz
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Marcus Rudolph
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,DRF Stiftung Luftrettung gemeinnützige AG, Filderstadt, Germany
| | - Michael Schöler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Tom Terboven
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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15
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Eisenkraft A, Gavish L, Wagnert-Avraham L, Gertz SD, Milner I, Shaylor R, Kushnir D, Kedar A, Mintz Y. Novel self-fixation chest drain device tested in a swine model of pneumo-hemothorax. MINIM INVASIV THER 2019; 30:40-46. [PMID: 31566510 DOI: 10.1080/13645706.2019.1671456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Thoracic injuries account for 20-25% of trauma-related deaths. In cases of pneumothorax the insertion of a chest tube is mandatory but associated with high complication rates particularly when inserted under difficult conditions. The C-Lant is a novel chest-tube insertion device that provides integrated double fixation capabilities and can be used by responders with minimal experience. The aim of the study was to test the device in a large animal model. MATERIAL AND METHODS Pneumothorax, tension pneumothorax, and hemothorax were induced in four white domestic female pigs. The C-Lant device (Vigor Medical Technologies, Haifa, Israel) was inserted as any chest-drain to decompress the thorax. Pull test was applied to test the strength of device fixation. RESULTS The insertion of the device was simple and effective without detectable negative physiological effects. Reliable fixation was achieved without difficulty. Air and liquid were promptly drained from the chest cavity. Minimal tissue laceration occurred when applying the device in a scenario of erroneous pneumothorax diagnosis with fully expanded lungs. Interconnection with other surgical accessories was smooth. CONCLUSION The C-Lant is a novel device that facilitates easy insertion and fixation of chest-tubes by minimally experienced medical providers and reduces the likelihood of unwanted expulsion. Clinical studies are planned.
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Affiliation(s)
- Arik Eisenkraft
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel, Israel Defense Forces Medical Corps
| | - Lilach Gavish
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel, Israel Defense Forces Medical Corps.,Saul and Joyce Brandman Cardiovascular Research Hub, The Institute for Medical Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Linn Wagnert-Avraham
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel, Israel Defense Forces Medical Corps
| | - S David Gertz
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel, Israel Defense Forces Medical Corps.,Saul and Joyce Brandman Cardiovascular Research Hub, The Institute for Medical Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Iris Milner
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel, Israel Defense Forces Medical Corps
| | - Ruth Shaylor
- The Department of Anesthesiology, Hadassah University Medical Center, Jerusalem, Israel
| | - David Kushnir
- The Department of Anesthesiology, Hadassah University Medical Center, Jerusalem, Israel
| | - Asaf Kedar
- Department of Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yoav Mintz
- Department of Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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16
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Can ultrasound be used as an adjunct for tube thoracostomy? A systematic review of potential application to reduce procedure-related complications. Int J Surg 2019; 68:85-90. [DOI: 10.1016/j.ijsu.2019.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/10/2019] [Accepted: 06/18/2019] [Indexed: 11/23/2022]
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17
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Dippenaar E, Wallis L. Pre-hospital intercostal chest drains in South Africa: A modified Delphi study. Afr J Emerg Med 2019; 9:91-95. [PMID: 31193823 PMCID: PMC6543074 DOI: 10.1016/j.afjem.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 10/24/2018] [Accepted: 01/04/2019] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Trauma is one of the most common causes of death in low- and middle-income countries, with thoracic injury accounting for 20-25% of these deaths worldwide. The current management of a life-threatening pre-hospital pneumothorax is with a needle chest decompression, however, definitive care for a pneumothorax and/or haemothorax is still the insertion of an intercostal chest drain. The aim of this study was to seek expert opinion and consensus on the placement of ICDs in the pre-hospital emergency care setting in South Africa. METHODS A three-round modified Delphi study was undertaken with an expert panel drawn from local emergency care experts consisting of physicians and emergency medical service practitioners. Participants supplied opinion statements in round 1 under headings derived from common emerging themes found in the literature. During round 2 participants used a 9-point Likert scale to rate their consensus on each statement and in round 3 they were able to change their position based on the earlier panel distributions. A consensus percentage of 60% was set within a narrow margin of 'strongly agree' or 'strongly disagree'. RESULTS A total of 22 experts took part as panel members. There were 123 opinion statements produced from round 1, of which 21 (17%) reached consensus in round 2. At the end of round 3 another four statements reached consensus, bringing the total up to 25 (20%). CONCLUSION Definitive care of a life-threating pneumothorax and/or haemothorax must be sought emergently. The insertion of an ICD, under select conditions, may be required in the pre-hospital setting in South Africa.
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18
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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.
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19
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Menegozzo CAM, Meyer-Pflug AR, Utiyama EM. How to reduce pleural drainage complications using an ultrasound- guided technique. Rev Col Bras Cir 2018; 45:e1952. [PMID: 30231114 DOI: 10.1590/0100-6991e-20181952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 07/15/2018] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Adriano Ribeiro Meyer-Pflug
- Hospital das Clínicas, Universidade de São Paulo, Disciplina de Cirurgia Geral e Trauma, São Paulo, SP, Brasil
| | - Edivaldo Massazo Utiyama
- Hospital das Clínicas, Universidade de São Paulo, Disciplina de Cirurgia Geral e Trauma, São Paulo, SP, Brasil
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20
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Menegozzo CAM, Utiyama EM. Steering the wheel towards the standard of care: Proposal of a step-by-step ultrasound-guided emergency chest tube drainage and literature review. Int J Surg 2018; 56:315-319. [DOI: 10.1016/j.ijsu.2018.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/20/2018] [Accepted: 07/03/2018] [Indexed: 11/16/2022]
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21
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Tension hydrothorax: Emergency decompression of a pleural cause of cardiac tamponade. Am J Emerg Med 2018; 36:1524.e1-1524.e4. [DOI: 10.1016/j.ajem.2018.04.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 11/21/2022] Open
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22
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Mendes CA, Hirano ES. Predictors of chest drainage complications in trauma patients. Rev Col Bras Cir 2018; 45:e1543. [PMID: 29668810 DOI: 10.1590/0100-6991e-20181543] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/09/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to identify predictors of chest drainage complications in trauma patients attended at a University Hospital. METHODS we conducted a retrospective study of 68 patients submitted to thoracic drainage after trauma, in a one-year period. We analyzed gender, age, trauma mechanism, trauma indices, thoracic and associated lesions, environment in which the procedure was performed, drainage time, experience of the performer, complications and evolution. RESULTS the mean age of the patients was 35 years and the male gender was the most prevalent (89%). Blunt trauma was the most frequent, with 67% of cases, and of these, 50% were due to traffic accidents. The mean TRISS (Trauma and Injury Severity Score) was 98, with a mortality rate of 1.4%. The most frequent thoracic and associated lesions were, respectively, rib fractures (51%) and abdominal trauma (32%). The mean drainage time was 6.93 days, being higher in patients under mechanical ventilation (p=0.0163). The complication rate was 26.5%, mainly poor drain positioning (11.77%). Hospital drainage was performed in 89% of cases by doctors in the first year of specialization. Thoracic drainage performed in prehospital care presented nine times more chances of complications (p=0.0015). CONCLUSION the predictors of post-trauma complications for chest drainage were a procedure performed in an adverse site and mechanical ventilation. The high rate of complications demonstrates the importance of protocols of care with the thoracic drainage.
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Affiliation(s)
- Cecília Araújo Mendes
- Faculty of Medical Sciences, Discipline of Trauma Surgery, Campinas State University, Campinas, SP, Brazil
| | - Elcio Shiyoiti Hirano
- Faculty of Medical Sciences, Post-Graduate Program, Campinas State University, Campinas, SP, Brazil
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23
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Rehfeldt M, Slagman A, Leidel BA, Möckel M, Lindner T. Point-of-Care Diagnostic Device for Traumatic Pneumothorax: Low Sensitivity of the Unblinded PneumoScan™. Emerg Med Int 2018; 2018:7307154. [PMID: 29805809 PMCID: PMC5899859 DOI: 10.1155/2018/7307154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/21/2018] [Accepted: 02/22/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Traumatic Pneumothorax (PTX) is a potentially life-threatening injury. It requires a fast and accurate diagnosis and treatment, but diagnostic tools are limited. A new point-of-care device (PneumoScan) based on micropower impulse radar (MIR) promises to diagnose a PTX within seconds. In this study, we compare standard diagnostics with PneumoScan during shock-trauma-room management. PATIENTS AND METHODS Patients with blunt or penetrating chest trauma were consecutively included in the study. All patients were examined including clinical examination with auscultation (CE) and supine chest radiography (CXR). In addition, PneumoScan-readings and thoracic ultrasound scan (US) were performed. Computed tomography (CT) served as gold standard. RESULTS CT scan revealed PTX in 11 patients. PneumoScan detected two PTX correctly but missed nine. 15 false-positive results were found by PneumoScan, leading to a sensitivity of 20% and specificity of 80%. Six PTX were detected through CE (sensitivity: 54,5%). CXR detected four (sensitivity: 27,3%) and thoracic US two PTX correctly (sensitivity: 25%). CONCLUSION The unblinded PneumoScan prototype did not confirm the promising results of previous studies. The examined standard diagnostics and thoracic US showed rather weak sensitivity as well. Until now, there is no appropriate point-of-care tool to rule out PTX.
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Affiliation(s)
- M. Rehfeldt
- Department of Anaesthesia & Intensive Care, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - A. Slagman
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - B. A. Leidel
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - M. Möckel
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - T. Lindner
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
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24
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Hashmi U, Nadeem M, Aleem A, Khan FUHH, Gull R, Ullah K, Khan IH. Dysfunctional Closed Chest Drainage - Common Causative Factors and Recommendations for Prevention. Cureus 2018; 10:e2295. [PMID: 29750136 PMCID: PMC5943031 DOI: 10.7759/cureus.2295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Dysfunctional closed chest drainage unit (CDU) dysfunction is a common but serious clinical problem associated with tube thoracostomy and results in a significant rise in morbidity, prolonged hospital stays, and increased economic burden. This observational study examines the proximate factors of closed CDU dysfunction in addition to their relative frequency. Based on our findings, we suggest logical recommendations for preventing the factors that contribute to closed chest drainage unit dysfunction. Method The study target population consists of all those individuals who had experienced tube thoracostomy for any pathology related to the chest cavity treated in the Department of Thoracic Surgery, Nishter Medical University, Multan, Pakistan, from February 2015 to January 2017. The study population was not restricted by age or gender. Of the 727 examined cases, only those patients who had experienced tube thoracostomy and had significant failure in draining the pleural collection were included in the study. Detailed histories were collected, and thorough physical examinations were carried out for each participant. Chest x-rays and, if needed, computed tomography (CT) scans were obtained to properly examine the placement of the chest tubes and detect the causative factor of the closed CDU dysfunction. Results A total of 139 cases were included in the study. The most common cause of closed CDU dysfunction was the use of the wrong CDU connection (n = 24, 17.3%). Other common problems included inadequate prime fluid use, loose connections, kinked tubes, and overly full bottles. Conclusion Closed CDU dysfunction may be prevented by adopting and following proper protocols for tube thoracostomy.
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Affiliation(s)
- Usman Hashmi
- Thoracic Surgery, Nishtar Medical University/hospital Multan, Pakistan
| | | | - Abdul Aleem
- Thoracic Surgery, Nishtar Medical University/hospital Multan, Pakistan
| | | | - Rabeea Gull
- Thoracic Surgery, Nishtar Medical University/hospital Multan, Pakistan
| | - Kaleen Ullah
- Thoracic Surgery, Nishtar Medical University/hospital Multan, Pakistan
| | - Iftikhar H Khan
- Thoracic Surgery, Nishtar Medical University/hospital Multan, Pakistan
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25
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Esmer E, Derst P, Lefering R, Schulz M, Siekmann H, Delank KS. [Prehospital assessment of injury type and severity in severely injured patients by emergency physicians : An analysis of the TraumaRegister DGU®]. Unfallchirurg 2018; 120:409-416. [PMID: 26757729 DOI: 10.1007/s00113-015-0127-3] [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] [Indexed: 10/22/2022]
Abstract
BACKGROUND Prehospital assessment of injury type and severity by emergency medical services physicians impacts treatment including appropriate destination hospital selection, especially in (potentially) life-threatening cases. Injuries which are underestimated or overlooked by the emergency physician can delay adequate therapy and thus significantly influence the overall outcome. The current study used data from the TraumaRegister DGU® to evaluate the reliability of prehospital injury assessments made by emergency physicians. MATERIAL AND METHODS Data of 30,777 patients from the TraumaRegister DGU® between 1993 and 2009 were retrospectively evaluated. Using the abbreviated injury scale (AIS), subjective prehospital assessments of injury severity by emergency physicians were correlated with objectively identified injuries diagnosed after admission to hospital. For this evaluation, prehospital injury assessments rated moderate or severe by the emergency physician as well as injuries diagnosed in hospital with an AIS score ≥3 points were deemed relevant. RESULTS The 30,777 patients with an injury severity score (ISS) ≥ 9 suffered a total of 202,496 injuries and of these 26 % (51,839 out of 202,496) were considered relevant with an AIS ≥3 points. The most frequent relevant injuries were to the head (47 %) and chest (46 %). Of the 51,839 relevant injuries, the prehospital assessment by the emergency physician was accurate for 71 % and in 29 % of the cases relevant injuries were underestimated. Relevant injuries were unrecognized or underestimated in prehospital assessments for almost 1 out of every 7 cases of head trauma, almost 1 out of every 3 thoracic trauma and almost 1 out of every 2 abdominal and pelvic trauma. CONCLUSION The assessment of injury severity by emergency medical services physicians based on physical examination at the scene of the trauma is not very reliable. Thus, mechanisms of injury and overall presentation as well as identifiable injuries and vital parameters should be recognized by the emergency physician when considering treatment strategies and choice of appropriate destination hospital. The patient should be re-evaluated in a priority-oriented manner at the latest on arrival in the trauma room to avoid the consequences of unrecognized or underestimated injuries.
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Affiliation(s)
- E Esmer
- Orthopädie und Unfallchirurgie, Asklepios Krankenhaus Harburg, Eißendorfer Pferdeweg 52, 21075, Hamburg, Deutschland.
| | - P Derst
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther- Universität Halle-Wittenberg, Magdeburger Straße 22, 06112, Halle(Saale), Deutschland
| | - R Lefering
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimer Str. 200, 51109, Köln, Deutschland
| | - M Schulz
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther- Universität Halle-Wittenberg, Magdeburger Straße 22, 06112, Halle(Saale), Deutschland
| | - H Siekmann
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther- Universität Halle-Wittenberg, Magdeburger Straße 22, 06112, Halle(Saale), Deutschland
| | - K-S Delank
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther- Universität Halle-Wittenberg, Magdeburger Straße 22, 06112, Halle(Saale), Deutschland
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Laplace C, Harrois A, Hamada S, Duranteau J. Traumatismes thoraciques non chirurgicaux. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0006] [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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Ablett DJ, Navaratne L, Chua D, Streets CG, Tai NRM. The modified 'Jo'burg' technique for securing intercostal chest drains. J ROY ARMY MED CORPS 2017; 163:319-323. [PMID: 28652316 DOI: 10.1136/jramc-2016-000744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/15/2017] [Accepted: 03/18/2017] [Indexed: 11/03/2022]
Abstract
Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as an emergency procedure during the initial resuscitation period and often within a stressful environment. Approximately one-fifth of all ICD insertions are associated with complications. In a retrospective review of over 1000 ICD insertions, 7% of the complications observed were due to inadequate fixation, resulting in dislodgement. The risk of dislodgement is greatest during transit or transfer of a casualty. In a military setting, this may involve movement of a casualty in a non-permissive environment and includes transfer on and off rotary wing, fixed wing, road vehicle and maritime transport platforms as well as between stretchers and hospital beds. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines, the method of securing ICDs has not been standardised across the Defence Medical Services (DMS). The aim of this paper is to first propose a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand. Second, we present the results from a pilot validation study of this technique when introduced to candidates on a trauma surgical skills course. We describe and demonstrate a robust, easily teachable and reproducible technique for securing ICDs. We would advocate the use of this technique among both surgically and non-surgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. This could be easily implemented by introducing this technique into the various military trauma courses, for example the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses.
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Affiliation(s)
- Daniel J Ablett
- Royal London Hospital, London, UK.,Defence Medical Services, DMS Whittington, Lichfield, UK
| | - L Navaratne
- Royal London Hospital, London, UK.,Defence Medical Services, DMS Whittington, Lichfield, UK
| | - D Chua
- Royal College of Surgeons of Ireland, Dublin, Ireland
| | - C G Streets
- Defence Medical Services, DMS Whittington, Lichfield, UK.,Bristol Royal Infirmary, Bristol, UK
| | - N R M Tai
- Royal London Hospital, London, UK.,Defence Medical Services, DMS Whittington, Lichfield, UK
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Meadley B, Olaussen A, Delorenzo A, Roder N, Martin C, St Clair T, Burns A, Stam E, Williams B. Educational standards for training paramedics in ultrasound: a scoping review. BMC Emerg Med 2017. [PMID: 28623905 PMCID: PMC5473963 DOI: 10.1186/s12873-017-0131-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Paramedic-performed out-of-hospital ultrasound is a novel skill that has gained popularity in some services in recent years. In this setting point-of care ultrasound (POCUS) can provide additional information that can assist with management and guide transport to the most appropriate facility. We sought to explore the different educational approaches used for training paramedics in ultrasound in the out-of-hospital setting. METHODS Ovid MEDLINE, EMBASE, EBM Reviews, The Cochrane Library, CINAHL plus, The Monash University Research Repository and the British Thesis Library were searched from the 1st of January 1990 to the 6th of April 2016. Google Scholar was searched and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital and POCUS educational approaches for paramedics. RESULTS A total of 2002 unique articles were identified of which 18 articles met the inclusion criteria. Most articles reported combined cohorts of emergency providers with varying years of experience though most operators were POCUS naïve. The most common clinical assessment for which paramedic POCUS curricula was described was the focused assessment sonography for trauma (FAST) examination. Education programs varied from two-minutes to two-days with all studies including both didactic and practical training. CONCLUSION Education programs for POCUS for paramedics vary considerably, and do not appear to align with qualification level or clinical experience. Further research investigating education and subsequent clinical application of POCUS by paramedics is required, as well as prospective, outcome based studies in order to measure the clinical utility of out-of-hospital POCUS.
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Affiliation(s)
- Ben Meadley
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia.
| | - Alexander Olaussen
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia
| | - Ashleigh Delorenzo
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia
| | - Nick Roder
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia
| | - Caroline Martin
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia
| | - Toby St Clair
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia
| | - Andrew Burns
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia
| | - Emma Stam
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia
| | - Brett Williams
- Department of Community Emergency Health and Paramedic Practice, Monash University - Peninsula Campus, PO Box 527, McMahons Road, Frankston, VIC, 3199, Australia
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Bouzat P, Raux M, David JS, Tazarourte K, Galinski M, Desmettre T, Garrigue D, Ducros L, Michelet P, Freysz M, Savary D, Rayeh-Pelardy F, Laplace C, Duponq R, Monnin Bares V, D'Journo XB, Boddaert G, Boutonnet M, Pierre S, Léone M, Honnart D, Biais M, Vardon F. Chest trauma: First 48hours management. Anaesth Crit Care Pain Med 2017; 36:135-145. [PMID: 28096063 DOI: 10.1016/j.accpm.2017.01.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Chest trauma remains an issue for health services for both severe and apparently mild trauma management. Severe chest trauma is associated with high mortality and is considered liable for 25% of mortality in multiple traumas. Moreover, mild trauma is also associated with significant morbidity especially in patients with preexisting conditions. Thus, whatever the severity, a fast-acting strategy must be organized. At this time, there are no guidelines available from scientific societies. These expert recommendations aim to establish guidelines for chest trauma management in both prehospital an in hospital settings, for the first 48hours. The "Société française d'anesthésie réanimation" and the "Société française de médecine d'urgence" worked together on the 7 following questions: (1) criteria defining severity and for appropriate hospital referral; (2) diagnosis strategy in both pre- and in-hospital settings; (3) indications and guidelines for ventilatory support; (4) management of analgesia; (5) indications and guidelines for chest tube placement; (6) surgical and endovascular repair indications in blunt chest trauma; (7) definition, medical and surgical specificity of penetrating chest trauma. For each question, prespecified "crucial" (and sometimes also "important") outcomes were identified by the panel of experts because it mattered for patients. We rated evidence across studies for these specific clinical outcomes. After a systematic Grade® approach, we defined 60 recommendations. Each recommendation has been evaluated by all the experts according to the DELPHI method.
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Affiliation(s)
- Pierre Bouzat
- Grenoble Alpes trauma centre, pôle anesthésie-réanimation, CHU de Grenoble, Inserm U1216, institut des neurosciences de Grenoble, université Grenoble Alpes, 38700 La Tronche, France
| | - Mathieu Raux
- SSPI - accueil des polytraumatisés, hôpital universitaire Pitié-Salpêtrière - Charles-Foix, 75013 Paris, France
| | - Jean Stéphane David
- Service d'anesthésie-réanimation, centre hospitalier Lyon Sud, faculté de médecine Lyon Est, université Lyon 1 Claude-Bernard, 69310 Pierre-Bénite, France
| | - Karim Tazarourte
- Service des urgences, pôle URMARS, groupement hospitalier Édouard-Herriot, hospices civils de Lyon, université Claude-Bernard Lyon 1, 69003 Lyon, France
| | - Michel Galinski
- Pôle urgences adultes - Samu, hôpital Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
| | - Thibault Desmettre
- Urgences/Samu CHRU de Besançon, université de Bourgogne Franche Comté, UMR 6249 CNRS/UFC, 25030 Besançon, France
| | | | - Laurent Ducros
- Service de réanimation polyvalente, pôle anesthésiologie, réanimation, hôpital Sainte-Musse, 83000 Toulon, France
| | - Pierre Michelet
- Services des urgences adultes, hôpital de la Timone, UMR MD2 - Aix Marseille université, 13005 Marseille, France.
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Leech C, Porter K, Steyn R, Laird C, Virgo I, Bowman R, Cooper D. The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408616664553] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
‘The pre-hospital management of chest injury: a consensus statement’ was originally published by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in 2007. To update the pre-existing guideline, a consensus meeting of stakeholders was held by the Faculty of Pre-hospital Care in Coventry in November 2013. This paper provides a guideline for the pre-hospital management of patients with the life-threatening chest injuries of tension pneumothorax, open pneumothorax, massive haemothorax, flail chest (including multiple rib fractures), and cardiac tamponade.
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Affiliation(s)
- Caroline Leech
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Keith Porter
- Academic Department of Clinical Traumatology, University of Birmingham, Birmingham, UK
| | - Richard Steyn
- Department of Thoracic Surgery, Heart of England NHS Trust, Birmingham, UK
| | | | - Imogen Virgo
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Richard Bowman
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - David Cooper
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
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Barbois S, Abba J, Guigard S, Quesada J, Pirvu A, Waroquet P, Reche F, Risse O, Bouzat P, Thony F, Arvieux C. Management of penetrating abdominal and thoraco-abdominal wounds: A retrospective study of 186 patients. J Visc Surg 2016; 153:69-78. [DOI: 10.1016/j.jviscsurg.2016.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Braude D, Tutera D, Tawil I, Pirkl G. Air transport of patients with pneumothorax: is tube thoracostomy required before flight? Air Med J 2016; 33:152-6. [PMID: 25049185 DOI: 10.1016/j.amj.2014.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 01/29/2014] [Accepted: 04/10/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE It is conventionally thought that patients with pneumothorax (PTX) require tube thoracostomy (TT) before air medical transport (AMT), especially in unpressurized rotor-wing (RW) aircraft, to prevent deterioration from expansion of the PTX or development of tension PTX. We hypothesize that patients with PTX transported without TT tolerate RW AMT without serious deterioration, as defined by hypotension, hypoxemia, respiratory distress, intubation, bag valve mask ventilation, needle thoracostomy (NT), or cardiac arrest during transport. METHODS We conducted a retrospective review of a case-series of trauma patients transported to a single Level 1 trauma center via RW with confirmed PTX and no TT. Using standardized abstraction forms, we reviewed charts for signs of deterioration. Those patients identified as having clinical deterioration were independently reviewed for the likelihood that the clinical deterioration was a direct consequence of PTX. RESULTS During the study period, 66 patients with confirmed PTX underwent RW AMT with an average altitude gain of 1890 feet, an average barometric pressure 586-600 mmHg, and average flight duration of 28 minutes. All patients received oxygen therapy; 14/66 patients (21%) were supported with positive pressure ventilation. Eleven of 66 patients (17%) had NT placed before flight and 4/66 (6%) had NT placed during flight. Four of 66 patients (6% CI0.3-11.7) may have deteriorated during AMT as a result of PTX; all were successfully managed with NT. CONCLUSIONS In this series, 6% of patients with PTX deteriorated as result of AMT without TT, yet all patients were managed successfully with NT. Routine placement of TT in patients with PTX before RW AMT may not be necessary. Further prospective evaluation is warranted.
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Affiliation(s)
| | | | - Issac Tawil
- University of New Mexico Health Science Center
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Abstract
Pre-hospital care is emergency medical care given to patients before arrival in hospital after activation of emergency medical services. It traditionally incorporated a breadth of care from bystander resuscitation to statutory emergency medical services treatment and transfer. New concepts of care including community paramedicine, novel roles such as emergency care practitioners, and physician delivered pre-hospital emergency medicine are re-defining the scope of pre-hospital care. For severely ill or injured patients, acting quickly in the pre-hospital period is crucial with decisions and interventions greatly affecting outcomes. The transfer of skills and procedures from hospital care to pre-hospital medicine enables early advanced care across a range of disciplines. The variety of possible pathologies, challenges of environmental factors, and hazardous situations requires management that is tailored to the patient's clinical need and setting. Pre-hospital clinicians should be generalists with a broad understanding of medical, surgical, and trauma pathologies, who will often work from locally developed standard operating procedures, but who are able to revert to core principles. Pre-hospital emergency medicine consists of not only clinical care, but also logistics, rescue competencies, and scene management skills (especially in major incidents, which have their own set of management principles). Traditionally, research into the hyper-acute phase (the first hour) of disease has been difficult, largely because physicians are rarely present and issues of consent, transport expediency, and resourcing of research. However, the pre-hospital phase is acknowledged as a crucial period, when irreversible pathology and secondary injury to neuronal and cardiac tissue can be prevented. The development of pre-hospital emergency medicine into a sub-specialty in its own right should bring focus to this period of care.
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Affiliation(s)
- Mark H Wilson
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK; St Mary's Major Trauma Centre, Imperial College, London, UK.
| | - Karel Habig
- Greater Sydney HEMS Service, Sydney, Australia
| | | | - Amy Hughes
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK
| | - Gareth Davies
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK
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Chesters A, Davies G, Wilson A. Four years of pre-hospital simple thoracostomy performed by a physician-paramedic helicopter emergency medical service team: A description and review of practice. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408615619197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Essex and Herts Air Ambulance Trust operate doctor-paramedic pre-hospital care teams. Simple thoracostomy is performed if an intubated patient requires pleural decompression. Reports of the use of this technique are uncommon in the literature. This study describes the use of pre-hospital thoracostomy over four years. Pre-hospital complications and effect on oxygen saturations were also noted. Methods A retrospective database review of all missions that occurred between 1 April 2010 and 31 March 2014. All patients undergoing this procedure were included. Results A total of 126 patients were identified. In 110 (87%) of the total number of patients, the procedure was bilateral making the total number of thoracostomies performed 236. The mechanism of injury was blunt trauma in 115 (91%) and penetrating trauma in 11 patients (9%). The primary indication was traumatic cardiac arrest or peri-arrest in 51 patients (40%), high risk of pneumothorax in a ventilated patient in 45 patients (36%), pneumothorax diagnosed prior to delivery of anaesthesia in 17 patients (13%), and unexplained hypoxia in a ventilated patient in 13 patients (10%). The mean pulse oximetry measurement at the time of arrival was 91.8% and 97.2% at the time of handover ( p=0.003). No immediate complications were recorded on the database. Conclusion We have described the regular use of the technique of simple thoracostomy in trauma patients attended by our air ambulance service. It is the largest case series to date of simple thoracostomy being used in the context of pre-hospital chest trauma.
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Abstract
Pre-hospital care requires a broad skillset. One of the most challenging aspects of pre-hospital care is performing surgical procedures. The indications and evidence for performing pre-hospital surgical airway, thoracostomy, thoracotomy, caesarean section and amputation are discussed. Where evidence for the procedure is lacking from pre-hospital care, evidence from in-hospital experience is sought.
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Prehospital interventions in severely injured pediatric patients. J Trauma Acute Care Surg 2015; 79:983-9; discussion 989-90. [DOI: 10.1097/ta.0000000000000706] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wernick B, Hon HH, Mubang RN, Cipriano A, Hughes R, Rankin DD, Evans DC, Burfeind WR, Hoey BA, Cipolla J, Galwankar SC, Papadimos TJ, Stawicki SP, Firstenberg MS. Complications of needle thoracostomy: A comprehensive clinical review. Int J Crit Illn Inj Sci 2015; 5:160-9. [PMID: 26557486 PMCID: PMC4613415 DOI: 10.4103/2229-5151.164939] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Needle thoracostomy (NT) is a valuable adjunct in the management of tension pneumothorax (tPTX), a life-threatening condition encountered mainly in trauma and critical care environments. Most commonly, needle thoracostomies are used in the prehospital setting and during acute trauma resuscitation to temporize the affected individuals prior to the placement of definitive tube thoracostomy (TT). Because it is both an invasive and emergent maneuver, NT can be associated with a number of potential complications, some of which may be life-threatening. Due to relatively common use of this procedure, it is important that healthcare providers are familiar, and ready to deal with, potential complications of NT.
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Affiliation(s)
- Brian Wernick
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Heidi H Hon
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Ronnie N Mubang
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Anthony Cipriano
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Ronson Hughes
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Demicha D Rankin
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - David C Evans
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - William R Burfeind
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Brian A Hoey
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - James Cipolla
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Sagar C Galwankar
- Department of Emergency Medicine, University of Florida, Jacksonville, Florida, United States
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Stanislaw P Stawicki
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, United States ; Department of Research and Innovation, St Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Michael S Firstenberg
- Cardiothoracic Surgery, Summa Health System and Northeastern Ohio Universities College of Medicine, Akron, Ohio, United States
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Traumatic tension pneumothorax: experience from 115 consecutive patients in a trauma service in South Africa. Eur J Trauma Emerg Surg 2015; 42:55-9. [PMID: 26038022 DOI: 10.1007/s00068-015-0502-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 02/23/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Traumatic tension pneumothorax (TPTX) is a life threatening condition, but literature describing this condition specifically in developing countries is scarce. MATERIALS AND METHODS We conducted a retrospective review of 115 patients with a TPTX, managed over a 4-year period in a high volume trauma service in South Africa. RESULTS A total of 118 TPTXs were identified in 115 patients. Eighty-nine percent (102/115) were males, and the mean age was 26 years (SD ± 6 years). Seventy-four percent (87/118) of all TPTXs occurred on the left side. The mechanisms of injury were penetrating in 71 % (82/115) [82 stab injuries], and blunt in 29 % (33/115) [31 road traffic accidents and 2 assaults]. Ninety-seven percent (111/115) of patients presented directly to our unit, while 3 % (4/115) were referrals from other hospitals. Fifteen percent (17/115) of needle decompressions were performed in the pre-hospital setting while the remaining 85 % (98/115) were performed on arrival (73 were recognised clinically and 25 were not). Of the 25 TPTXs that were not recognised clinically on initial assessment, 12 were discovered on CXR, 8 on CT scans and 5 in the operating room (OR). The overall mortality was 9 % (10/115) [7 in CXR, 2 in CT, 1 in OR]. None of the patients who had the TPTXs identified on initial clinical assessment died (0/73), compared with those who were missed on initial clinical assessment, in which the mortality was significantly higher at 40 % (10/25), (p < 0.001). CONCLUSIONS Penetrating injuries accounted for the majority of TPTXs seen in our setting. Clinical recognition of the entity may be challenging and delayed recognition is associated with significant mortality.
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Traumatisme thoracique : prise en charge des 48 premières heures. ANESTHESIE & REANIMATION 2015. [DOI: 10.1016/j.anrea.2015.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Kanai M, Sekiguchi H. Avoiding vessel laceration in thoracentesis: a role of vascular ultrasound with color Doppler. Chest 2015; 147:e5-e7. [PMID: 25560873 DOI: 10.1378/chest.14-0814] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Thoracentesis is considered a relatively safe and well-established procedure commonly done at the bedside with minimal risk of complication. Thoracentesis-related hemothorax is uncommon; however, it may be life-threatening. We describe a case of a 19-year-old woman with persistent fever and pleural effusion, in which thoracentesis resulted in tension hemothorax due to intercostal artery laceration. It is important for proceduralists to understand not only the tortuosity of the intercostal artery covering 25% to 50% of the intercostal space, but also the presence of traversing collateral arteries. Herein, we discuss the potential benefit of vascular ultrasonography with color Doppler during thoracentesis, with the goal of avoiding vessel injury and hemorrhage.
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Affiliation(s)
- Mio Kanai
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Mayo Foundation for Medical Education and Research, Rochester, MN
| | - Hiroshi Sekiguchi
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Mayo Foundation for Medical Education and Research, Rochester, MN..
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Penetrating cardiac injury as the result of pre-hospital needle decompression. Heart Lung Circ 2015. [DOI: 10.1016/j.hlc.2014.12.149] [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]
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Hakala T, Vironen J, Karlsson S, Pajarinen J, Hirvensalo E, Paajanen H. Fatal surgical or procedure-related complications: a Finnish registry-based study. World J Surg 2014; 38:759-64. [PMID: 24271697 DOI: 10.1007/s00268-013-2364-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010. MATERIALS AND METHODS In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry. RESULTS Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors. CONCLUSION Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.
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Affiliation(s)
- Tapio Hakala
- Departments of Surgery and Anesthesiology, North Karelia Central Hospital, Tikkamaentie 16, 80201, Joensuu, Finland,
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Mefire AC, Fokou M, Dika LD. Indications and morbidity of tube thoracostomy performed for traumatic and non-traumatic free pleural effusions in a low-income setting. Pan Afr Med J 2014; 18:256. [PMID: 25489361 PMCID: PMC4258205 DOI: 10.11604/pamj.2014.18.256.3963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 07/15/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Tube thoracostomy (TT) is widely used to resolve a number of pleural conditions. Few data are available on the complications of TT performed for non-traumatic conditions, especially in low income setting. The aim of this study is to analyse the indications and complications of TT performed for both traumatic and non-traumatic conditions of the chest in a low-income environment. METHODS This retrospective study conducted over a four years period in a the Regional Hospital, Limbe in South-West Cameroon analyses the rate and nature of complications after TT performed for both traumatic and non-traumatic conditions. Different factors related to complications are analysed. RESULTS We analysed 134 patients who had 186 chest tubes inserted. After placement, tubes were either connected to a water seal system (40%) or submitted to suction (60%). Most (91%) procedures were performed for a non-traumatic condition. Non-infectious pleural effusion in patients with HIV infection or pulmonary tuberculosis was the most common indication. Sixty six per-cents of procedures were carried out by a general surgeon. The complication rate was 19.35%. The most common complications included tube dislocation and pneumothorax. Most complications were solved by replacement of the tube. The nature of operator (general surgeon vs general practitioner) was a significant predictor of outcome (p < 0.01). No procedure related death was recorded. CONCLUSION TT is a safe and efficient procedure to drain pleural collections of both traumatic and non-traumatic origins, even in low-income settings. The incidence of complications could be reduced by a better training of general practitioners on this procedure.
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Affiliation(s)
- Alain Chichom Mefire
- Regional Hospital Limbé and Faculty of Health Sciences, University of Buea, Yaoundé, Cameroon
| | - Marcus Fokou
- General and Reference Hospital, Yaoundé, Cameroon
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Affiliation(s)
- Mark Harrison
- Consultant in Emergency Medicine in the Emergency Department, Wansbeck General Hospital, Northumbria Healthcare NHS Trust, Ashington
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Knotts D, Arthur AO, Holder P, Herrington T, Thomas SH. Pneumothorax volume expansion in helicopter emergency medical services transport. Air Med J 2014; 32:138-43. [PMID: 23632222 DOI: 10.1016/j.amj.2012.10.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 10/20/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In accordance with Boyle's law (as barometric pressure decreases, gas volume increases), thoracostomy is often recommended for patients with pneumothoraces before helicopter EMS (HEMS) transport. We sought to characterize altitude-related volume changes in a pneumothorax model, aiming to improve clinical decisions for preflight thoracostomy in HEMS patients. METHODS This prospective study used 3 devices to measure air expansion at HEMS altitudes. The main device was an artificial pneumothorax model that mimicked a human pulmonary system with a 40 mL pneumothorax. In addition, volume changes were calculated in 2 spherical balloons (6 L and 25 L) by measuring equatorial circumferences. Measurements were recorded at 500-foot altitude increments from 1000 to 5000 feet above ground level. RESULTS The 3 models exhibited volume increases of 12.7%-16.2% at 5000 feet compared to ground level. Univariate linear regression yielded similar increases, 1.27%-1.52%, in volume per 500-foot altitude increase for all 3 models. Bivariate indexed linear regression identified no association between volume increase and assessment model (P values .19 and .29). Locally weighted scatterplot smoothing (lowess) plots indicated linearity of the altitude-volume relationship. CONCLUSION This study demonstrated predictable pneumothorax volume changes at typical HEMS altitudes. Increased understanding of altitude-related volume changes will aid decision making before transport.
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Affiliation(s)
- Derek Knotts
- Department of Emergency Medicine, University of Oklahoma School of Community Medicine and Hillcrest Medical Center, Tulsa, OK 74104, USA
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Does Radar Technology Support the Diagnosis of Pneumothorax? PneumoScan-A Diagnostic Point-of-Care Tool. Emerg Med Int 2013; 2013:489056. [PMID: 24187624 PMCID: PMC3800628 DOI: 10.1155/2013/489056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 08/09/2013] [Accepted: 08/12/2013] [Indexed: 12/02/2022] Open
Abstract
Background. A nonrecognized pneumothorax (PTX) may become a life-threatening tension PTX. A reliable point-of-care diagnostic tool could help in reduce this risk. For this purpose, we investigated the feasibility of the use of the PneumoScan, an innovative device based on micropower impulse radar (MIR). Patients and Methods. addition to a standard diagnostic protocol including clinical examination, chest X-ray (CXR), and computed tomography (CT), 24 consecutive patients with chest trauma underwent PneumoScan testing in the shock trauma room to exclude a PTX. Results. The application of the PneumoScan was simple, quick, and reliable without functional disorder. Clinical examination and CXR each revealed one and PneumoScan three out of altogether four PTXs (sensitivity 75%, specificity 100%, positive predictive value 100%, and negative predictive value 95%). The undetected PTX did not require intervention. Conclusion. The PneumoScan as a point-of-care device offers additional diagnostic value in patient management following chest trauma. Further studies with more patients have to be performed to evaluate the diagnostic accuracy of the device.
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Kirmani B, Zacharias J. Insertion of a chest drain for pneumothorax. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2013. [DOI: 10.1016/j.mpaic.2013.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Heavyside A. Sticking the knife in: Time to review management of tension pneumothorax. ACTA ACUST UNITED AC 2013. [DOI: 10.12968/jpar.2013.5.3.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lockey DJ, Lyon RM, Davies GE. Development of a simple algorithm to guide the effective management of traumatic cardiac arrest. Resuscitation 2012; 84:738-42. [PMID: 23228555 DOI: 10.1016/j.resuscitation.2012.12.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 11/13/2012] [Accepted: 12/01/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Major trauma is the leading worldwide cause of death in young adults. The mortality from traumatic cardiac arrest remains high but survival with good neurological outcome from cardiopulmonary arrest following major trauma has been regularly reported. Rapid, effective intervention is required to address potential reversible causes of traumatic cardiac arrest if the victim is to survive. Current ILCOR guidelines do not contain a standard algorithm for management of traumatic cardiac arrest. We present a simple algorithm to manage the major trauma patient in actual or imminent cardiac arrest. METHODS We reviewed the published English language literature on traumatic cardiac arrest and major trauma management. A treatment algorithm was developed based on this and the experience of treatment of more than a thousand traumatic cardiac arrests by a physician - paramedic pre-hospital trauma service. RESULTS The algorithm addresses the need treat potential reversible causes of traumatic cardiac arrest. This includes immediate resuscitative thoracotomy in cases of penetrating chest trauma, airway management, optimising oxygenation, correction of hypovolaemia and chest decompression to exclude tension pneumothorax. CONCLUSION The requirement to rapidly address a number of potentially reversible pathologies in a short time period lends the management of traumatic cardiac arrest to a simple treatment algorithm. A standardised approach may prevent delay in diagnosis and treatment and improve current poor survival rates.
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Affiliation(s)
- David J Lockey
- Pre-hospital Care, London's Air Ambulance, Royal London Hospital, London E1 1BB & School of Clinical Sciences, University of Bristol, United Kingdom.
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Jenkins JA, Gharahbaghian L, Doniger SJ, Bradley S, Crandall S, Spain DA, Williams SR. Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement. West J Emerg Med 2012; 13:305-11. [PMID: 22942927 PMCID: PMC3421967 DOI: 10.5811/westjem.2011.10.6680] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 06/22/2011] [Accepted: 10/03/2011] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement. METHODS This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigator using first the low-frequency (5-1 MHz) followed by the high-frequency (10-5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation of TT placement. RESULTS Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10-5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode. CONCLUSION Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10-5 MHz) linear transducer.
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