[Chest decompression in emergency medicine and intensive care]

Safety and Risk Factors of Needle Thoracentesis Decompression in Tension Pneumothorax in Patients over 75 Years Old

Background

There are very few professional recommendations or guidelines on the needle thoracentesis decompression (NTD) for the tension pneumothorax in the elderly. This study aimed to investigate the safety and risk factors of tension pneumothorax NTD in patients over 75 years old based on CT evaluation of the chest wall thickness (CWT).

Methods

The retrospective study was conducted among 136 in-patients over 75 years old. The CWT and closest depth to vital structure of the second intercostal space at the midclavicular line (second ICS-MCL) and the fifth intercostal space at the midaxillary line (fifth ICS-MAL) were compared as well as the expected failure rates and the incidence of severe complications of different needles. We also analyzed the influence of age, sex, presence or absence of chronic obstructive pulmonary disease (COPD), and body mass index (BMI) on CWT.

Results

The CWT of the second ICS-MCL was smaller than the fifth ICS-MAL both on the left and the right side (P < 0.05). The success rate associated with a 7 cm needle was significantly higher than a 5 cm needle (P < 0.05), and the incidence of severe complications with a 7 cm needle was significantly less than an 8 cm needle (P < 0.05). The CWT of the second ICS-MCL was significantly correlated with age, sex, presence or absence of COPD, and BMI (P < 0.05), whereas the CWT of the fifth ICS-MAL was significantly correlated with sex and BMI (P < 0.05).

Conclusion

The second ICS-MCL was recommended as the primary thoracentesis site and a 7 cm needle was advised as preferred needle length for the older patients. Factors such as age, sex, presence or absence of COPD, and BMI should be considered when choosing the appropriate needle length.

[Safety aspects of prehospital thoracic emergency procedures: Results of a survey among German emergency physicians]

BACKGROUND

The safe indication and performance of thoracic emergency procedures are crucial and potentially lifesaving in prehospital emergency care. This study aims to investigate issues of patient safety and quality assurance of prehospital invasive thoracic interventions. The survey does not represent the actual medical care situation but explores reasons for security concerns among emergency physicians.

METHODS

Using a pre-validated questionnaire, prehospital emergency physicians of three prehospital rescue associations (Zweckverband) in Southwest Saxony, Greifswald, and Vechta, Germany, were queried via the online survey service limesurvey. The survey was conducted between January and March 2022.

RESULTS

104 emergency physicians participated (response rate 42.4%) 71 of which fully completed the survey (68%). 79% of the participants stated that they felt safe in performing pleural punction. Common reasons for postponing prehospital thoracic interventions included fear of complications or individual patient characteristics. 90% said that they were familiar with the on-board equipment options, and 60% reported that resources were sufficient to perform double-sided procedures. While in all three regions there is sufficient on-board equipment to perform procedures on two sides, one out of two participants said that lack of equipment deters them from performing prehospital invasive thoracic procedures. Emergency physicians who graduated from trauma courses and/or participate in air rescue are more likely to perform invasive thoracic procedures. More than half of the participants wanted more training in chest tube placement or pleural punction.

CONCLUSION

Safety in prehospital invasive thoracic procedures needs improvement in structural, procedural, as well as human factors aspects. Safe handling of these rare but vital techniques requires more training. A lack of knowledge of equipment is a significant safety gap. Prehospital ultrasound constitutes a structural element of prehospital diagnostics.

Development and validation of the first performance assessment scale for interdisciplinary chest tube insertion: a prospective multicenter study

PURPOSE

Chest tube insertion requires interdisciplinary teamwork including an emergency surgeon or physician in conjunction with a nurse. The purpose of the study was to validate an interdisciplinary performance assessment scale for chest tube insertion developed from literature analysis.

METHODS

This prospective study took place in the simulation center of the University of Paris. The participants included untrained emergency/intensivist residents and trained novice emergency/intensivist physicians with less than 2 years of clinical experience and 6 months following training in thoracostomy, and nursing students. Each interdisciplinary pair participated in a high-fidelity simulation session. Two independent observers (O1 and O2) evaluated 61 items. Internal coherence using the Cronbach's α coefficient, intraclass correlation coefficient (ICC), and correlation of scores by regression analysis (R2) were analyzed. Comparison between O1 and O2 mean scores used a t test and F test for SDs. p Value < 0.05 was significant.

RESULTS

From an initial selection of 11,277 articles, 19 were selected to create the initial scale. The final scale comprises 61 items scored out of 80, including 24 items for nursing items, 24 items for medical competence, and 13 mixed items for the competence of both. 40 simulations including 80 participants were evaluated. Cronbach's α = 0.76, ICC = 0.92, R2 = 0.88. There was no difference between the observers' assessments of means (p = 0.82) and SDs (p = 0.92). Score was 51.6 ± 5.9 in the group of untrained residents and nursing student, and 57.2 ± 2.8 in the trained group of novice physicians and nursing students (p = 0.0003).

CONCLUSIONS

This first performance assessment scale for interdisciplinary chest tube insertion is valid and reliable.

Safety of the anterior approach versus the lateral approach for chest tube insertion by residents treating spontaneous pneumothorax: a propensity score weighted analysis

OBJECTIVE

To compare the risk of chest tube malposition, the most common complication during chest tube insertion, with the anterior or lateral approach for thoracostomy performed for patients with spontaneous pneumothorax by junior and senior residents.

METHODS

We retrospectively included patients aged ≥ 20 years who exhibited primary or secondary spontaneous pneumothorax without pleural adhesion and underwent chest tube drainage performed by junior or senior residents at tertiary care hospital. The study exposure involved insertion of the chest tube in the midclavicular line (anterior approach) or the anterior or midaxillary line (lateral approach). The primary outcome was the number of chest tube malpositions. Multiple imputation was used for missing data. The inverse probability of treatment weighting method was used to adjust for baseline confounders.

RESULTS

We identified 34 and 219 patients who underwent thoracostomy using the midclavicular and lateral approaches, respectively. The number of chest tube malpositions was 4 (11.8%) in the anterior approach and 34 (15.5%) in the lateral approach. The inverse probability of treatment weighting analysis revealed that the estimated odds ratio for chest tube malposition in the anterior approach group versus the lateral approach group was 0.61 (95% confidence interval, 0.17-2.11). The duration of chest tube drainage and the number of operations for persistent air leaks were not significantly different between the groups.

CONCLUSIONS

The current study revealed that the risk of chest tube malposition in thoracostomies with the midclavicular approach was not different from that with the lateral approach.

[Ultrasound Course in Ifakara (Tanzania) with Case Studies]

Ultrasound Course in Ifakara (Tanzania) with Case Studies Abstract. Presentation of two practical cases from the ultrasound course in Ifakara, Tanzania. Case 1 shows the diagnostic value of abdominal and thorax ultrasound in a polytraumatized patient with splenic rupture. In case 2 the sonographic signs of pulmonary and extrapulmonary tuberculosis are presented.