The risk of percutaneous chest tube thoracostomy for blunt thoracic trauma

doi:10.1016/S0196-0644(85)80635-1

Annals of Emergency Medicine

Volume 14, Issue 9, September 1985, Pages 865-870

https://doi.org/10.1016/S0196-0644(85)80635-1 Get rights and content

Analysis of 164 percutaneous chest tube thoracostomies performed as a standardized technical procedure in the management of 129 blunt trauma victims demonstrated an overall complication rate of 9.1% (15 of 164). Three complications (1.8%) were related to problems of insertion, and four (2.4%) represented the problem of pneumothorax after chest tube removal. The remaining eight complications (4.9%) were associated with positive bacterial cultures, two (1.2%) of which represented clinical empyema. Both cases of empyema had either prolonged chest tube placement (23 and 15 days) or multiple chest tubes (two and three) on the same side. Percutaneous chest tube thoracostomy remains an important facet in the management of certain types of blunt thoracic trauma. Associated risks can best be minimized with adherence to a standardized technique and management protocol.

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Cited by (71)

Asymptomatic non-occult pneumothorax in pediatric blunt chest trauma: Chest tube versus observation
2021, Journal of Pediatric Surgery
Citation Excerpt :
The implication of the result of this study is that CT placement may not be required in pediatric patients with apical, small, or moderate ANOPTX. This will likely save the pediatric trauma patients from a potentially unnecessary invasive procedure and the estimated 9–15% of complications (such as misplaced CT, infection and lung parenchymal injury) association with CT placement [13,14]. The hospital LOS was significantly shorter in patients who were observed compared to those who had CT placement.
The treatment of asymptomatic non-occult pneumothoraces (ANOPTX) secondary to blunt chest trauma (BCT) has not been well delineated. We sought to analyze our experience with ANOPTX in pediatric trauma patients and determine if a chest tube (CT) is mandatory.
A retrospective chart review of patients < 17 years old with ANOPTX from BCT who presented to a level 1 trauma children's hospital, between January 2000 and June 2015 was performed. Demographics, vitals, trauma scores, imaging, interventions, hospital expenses and outcomes were analyzed.
Of the 77 patients who had ANOPTX, 48 (62.3%) were managed with observation only, while 29 (37.7%) underwent CT placement. The median length of stay for patients who had CT placement was 7 days (IQR, 4, 12) and 2 days (IQR, 1, 4) in those observed (p < 0.01). All patients who were observed had complete resolution of the pneumothorax without recurrence or the need for CT placement. Patients who had CT placement had more imaging performed and more hospital expenditure compared to those who were observed.
CT is not mandatory in all pediatric patients with ANOPTX from BCT and observation has been found to be safe and cost effective.
Is a chest radiograph after thoracostomy tube removal necessary? A cost-effective analysis
2020, Injury
Citation Excerpt :
After uncomplicated TT re-insertion we assumed complete resolution of the PTX with no further recurrence or need for surgical intervention (thoracoscopy or thoracotomy). This assumption was based on the published literature where surgical interventions were not needed for PTX resolution in patients meeting our base case definition [5–7,14,18,20–22]. Additionally, our cost estimates for clinical observation after TT removal are based on a same day discharge, or if admission were still indicated for other traumatic injuries that no further TT related costs accrued.
Following placement of tube thoracostomy (TT) for evacuation of traumatic hemopneumothorax (HPTX), controversy persists over the need for routine post-TT removal chest radiograph (CXR). Current research demonstrates routine CXR may offer no advantage over clinical observation alone while simultaneously increasing hospital resource utilization. As such, we hypothesized that in resolved traumatic HPTXs routine post-TT removal CXR to assess recurrent PTX compared to clinical observation is not cost-effective.
We performed a decision-analytic model to evaluate the cost-effectiveness of routine CXR compared to clinical observation following TT removal. Our base case was a patient that sustained thoracic trauma with radiographic and clinical resolution of HPTX following TT evacuation. Cost, utility and probability estimates were generated from published literature, with costs represented in 2019 US dollars and utilities in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed.
Decision-analytic model identified that clinical observation after TT removal was the dominant strategy with increased benefit at less cost, when compared to routine CXR, with a net cost of $194.92, QALYs of 0.44. In comparison, routine CXR demonstrated an increase of $821.42 in cost with 0.43 QALYs. On probabilistic sensitivity analysis the clinical observation strategy was found cost-effective in 99.5% of 10,000 iterations.
In trauma patients with clinical and radiographic evidence of a resolved HPTX, the adoption of clinical observation in lieu of post-TT removal CXR is cost-effective. Routine CXR following TT removal accrues more cost without additional benefit. The practice of routinely obtaining a CXR following TT removal should be scrutinized.
Blunt trauma related chest wall and pulmonary injuries: An overview
2020, Chinese Journal of Traumatology - English Edition
Citation Excerpt :
Tube thoracostomy is the most commonly used method for the management and treatment of hemothorax. The aim of tube thoracostomy are (1) to clear the pleural space as much as possible (2) to provide re-expansion of the lungs (3) to create a buffer effect by contacting the lung with the parietal pleura (4) to measure the amount of blood lost and (5) to reduce the risk of complications such as empyema and fibrothorax.16,87,150,151 After tube thoracostomy, the continuation of radiopacity on thorax radiograph indicates that blood coagulates in the pleural space.
Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.
Emergency Medical Services Simple Thoracostomy for Traumatic Cardiac Arrest: Postimplementation Experience in a Ground-based Suburban/Rural Emergency Medical Services Agency
2018, Journal of Emergency Medicine
Citation Excerpt :
What is clear is that both approaches have significant failure rates and issues related to misplacement and iatrogenic injury (13–24). Given the problematic nature of needle decompression, tube thoracostomy has clear advantages but has reported complication rates ranging from 3–30% (25–29). Given the austere environments of prehospital medicine and the complication rate of tube thoracostomy, simple or finger thoracostomy may represent the most rational approach to thoracostomy in the prehospital setting.
Tube thoracostomy has long been the standard of care for treatment of tension pneumothorax in the hospital setting yet is uncommon in prehospital care apart from helicopter emergency medical services.
We aimed to evaluate the performance of simple thoracostomy (ST) for patients with traumatic cardiac arrest and suspected tension pneumothorax.
We conducted a retrospective case series of consecutive patients with traumatic cardiac arrest where simple thoracostomy was used during the resuscitation effort. Data were abstracted from our Zoll emergency medical record (Zoll Medical Corp., Chelmsford, MA) for patients who received the procedure between June 1, 2013 and July 1, 2017. We collected general descriptive characteristics, procedural success, presence of air or blood, and outcomes for each patient.
During the study period we performed ST on 57 patients. The mean age was 41 years old (range 15–81 years old) and 83% were male. Indications included 40 of 57 (70%) blunt trauma and 17 of 57 (30%) penetrating trauma. The presenting rhythm was pulseless electrical activity 65%, asystole 26%, ventricular tachycardia/fibrillation 4%, and nonrecorded 5%. Eighteen of 57 (32%) had air return, 14 of 57 (25%) return of spontaneous circulation, with 6 of 57 (11%) surviving to 24 h and 4 of 57 (7%) discharged from the hospital neurologically intact. Of the survivors, all were blunt trauma mechanism with initial rhythms of pulseless electrical activity. There were no reported medic injuries.
Our data show that properly trained paramedics in ground-based emergency medical services were able to safely and effectively perform ST in patients with traumatic cardiac arrest. We found a significant (32%) presence of pneumothorax in our sample, which supports previously reported high rates in this patient population.
An initial description of a sonographic sign that verifies intrathoracic chest tube placement
2010, American Journal of Emergency Medicine
An initial description of a sonographic finding predictive of intrathoracic chest tube placement.
This was a prospective observational study using unembalmed cadaveric models. Chest tubes were randomly placed intra- and extrathoracically and evaluated using ultrasound. Chest tube location was confirmed using blunt dissection followed by tactile and visual confirmation. Sonographers were blinded to chest tube position. Sonographic images obtained in a transverse orientation revealed a subcutaneous hyperechoic arc, created by the chest tube, at the insertion site. The path of the hyperechoic arc was followed cephalad. Disappearance of the hyperechoic arc signified intrathoracic chest tube placement. In contrast, continuation of a subcutaneous hyperechoic arc for the full length of the chest tube signified extrathoracic chest tube placement (the Disappearance/Intrathoracic, Continuation/Extrathoracic sign).
Ultrasound was used to evaluate 48 chest tube placements. All chest tube locations were identified correctly. In differentiating intra- vs extrathoracic chest tube placement, the Disappearance/Intrathoracic, Continuation/Extrathoracic sign revealed a sensitivity of 100% (95% confidence interval, 83%-100%) and a specificity of 100% (95% confidence interval, 83%-100%).
In this small study, bedside ultrasound appears to be highly sensitive and specific in differentiating intra- versus extrathoracic chest tube placement.
Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review
2007, Resuscitation
Pre-hospital insertion of chest tubes or decompression of air within the pleural space is one of the controversial topics in emergency medical care of trauma patients. While a wide variety of opinions exist medical personnel on the scene require guidance in situations when tension pneumothorax or progressive pneumothorax is suspected. To ensure evidence based decisions we performed a systematic review of the current literature with respect to the diagnostic accuracy in the pre-hospital setting to identify patients with (tension) pneumothorax, the efficacy and safety of performing pleural decompression in the field and the choice of method and technique for the procedure. The evidence found is presented and discussed and recommendations are drawn from the authors’ perspective.

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Original contributionThe risk of percutaneous chest tube thoracostomy for blunt thoracic trauma

Am J Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am J Surg

Empyema occurring in the multiply traumatized patient

J Trauma

A rural regional trauma center

J Trauma

Original contribution
The risk of percutaneous chest tube thoracostomy for blunt thoracic trauma