The spectrum of visceral injuries secondary to misplaced intercostal chest drains: experience from a high volume trauma service in South Africa

Construction and Evaluation of a Realistic Low-Cost Model for Training in Chest-Tube Insertion

INTRODUCTION

Emergency thoracostomy is applied in life-threatening situations. Simulation plays a pivotal role in training in invasive techniques used mainly in stressful situations. Currently available commercial simulation models for thoracostomy have various drawbacks.

METHODS

We designed a thoracostomy phantom from discarded hospital materials and pigskin with underlying flesh. The phantom can be used alone for developing technical skills or mounted on an actor in simulation scenarios. Medical students, intensive care unit (ICU) and emergency department teams, and thoracostomy experts evaluated its technical fidelity and usefulness for achieving learning objectives in workshops.

RESULTS

The materials used to construct the phantom cost €47. A total of 12 experts in chest-tube placement and 73 workshop participants (12 ICU physicians and nurses, 20 emergency physicians and nurses, and 41 fourth-year medical students) evaluated the model. All groups rated the model's usefulness and the sensation of perforating the pleura highly. Experts rated the air release after pleura perforation lower than other groups. Lung reexpansion was the lowest rated item in all groups. Ratings of the appearance and feel of the model correlated strongly among all groups and experts. The ICU professionals rated the resistance encountered in introducing the chest drain lower than the other groups.

CONCLUSIONS

This low-cost, reusable, transportable, and highly realistic model is an attractive alternative to commercial models for training in chest-tube insertion skills.

Thoracostomy tube withdrawal during latter phases of expiration or inspiration: a systematic review and meta-analysis

PURPOSE

In patients with thoracic injuries, tube thoracostomy is routinely employed. There is disagreement over which manner of tube withdrawal is best, the latter phases of expiration or inspiration. Considering several earlier investigations' inconsistent findings, their comparative effectiveness is still up for debate. In light of this, we carried out a systematic analysis of studies contrasting the withdrawal of thoracostomy tubes during the latter stages of expiration versus inspiration for traumatic chest injuries. Analyzed outcomes are recurrent pneumothoraces, reinsertion of the thoracostomy tube, and hospital stay.

METHODS

We looked for papers comparing the withdrawal of the thoracostomy tube during the last stages of expiration and inspiration for the management of thoracic injuries on Embase, Pubmed, Cochrane Library and Google Scholar. Review Manager was used to determine mean differences (MD) and risk ratios (RR) using a 95% confidence interval (CI).

RESULTS

The primary outcomes showed no significant difference between the inspiration and expiration groups: recurrent pneumothorax (RR 1.27, 95% CI 0.83-1.93, P 0.28) and thoracostomy tube reinsertion (OR: 1.84, CI 0.50-6.86, P 0.36, I2 5%). However, the duration of hospital stay was significantly lower in patients in whom the thoracostomy tube was removed at the end of inspiration (RR 1.8, 95% CI 1.49-2.11, P < 0.00001, I2 0%). The implications of these findings warrant cautious interpretation, accounting for potential confounding factors and inherent limitations that may shape their significance.

CONCLUSION

The thoracostomy tube can be removed during both the end-expiratory and end-inspiratory stages of respiration with no appreciable difference. Nevertheless, caution should be exercised when ascertaining the implications of these findings, taking into account the potential limitations and confounding variables that may exert influence upon the outcomes.

Mid‐Arm Point in PAEDiatrics (MAPPAED): An effective procedural aid for safe pleural decompression in trauma

OBJECTIVE

Life-threatening thoracic trauma requires emergency pleural decompression and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children can be challenging. We assessed whether the Mid-Arm Point (MAP) technique, a procedural aid proposed for use with injured adults, would also identify a safe site for pleural decompression in children.

METHODS

Children (0-18 years) attending four EDs were prospectively recruited. The MAP technique was performed, and chest wall skin marked bilaterally at the level of the MAP; no pleural decompression was performed. Radio-opaque markers were placed over the MAP-determined skin marks and corresponding intercostal space (ICS) reported using chest X-ray.

RESULTS

A total of 392 children participated, and 712 markers sited using the MAP technique were analysed. Eighty-three percentage of markers were sited within the 'safe zone' for pleural decompression (4th to 6th ICSs). When sited outside the 'safe zone', MAP-determined markers were typically too caudal. However, if the site for pleural decompression was transposed one ICS cranially in children ≥4 years, the MAP technique performance improved significantly with 91% within the 'safe zone'.

CONCLUSIONS

The MAP technique reliably determines a safe site for pleural decompression in children, albeit with an age-based adjustment, the Mid-Arm Point in PAEDiatrics (MAPPAED) rule: 'in children aged ≥4 years, use the MAP and go up one ICS to hit the safe zone. In children <4 years, use the MAP.' When together with this rule, the MAP technique will identify a site within the 'safe zone' in 9 out of 10 children.

Recurrent pneumothorax following chest tube removal in thoracic stab wounds: a comparative study between end inspiratory versus end expiratory removal techniques at a major trauma centre in South Africa

BACKGROUND

Tube thoracostomy (TT) insertion is a commonly performed procedure in trauma that is standardised, but the optimal removal technique based on the timing in relation to the respiratory cycle remains controversial.

METHODS

A prospective study was undertaken at a major trauma centre in South Africa over a 4-year period from January 2010 to December 2013, and included all patients with pneumothorax secondary to thoracic stab wounds. TTs were removed by either end of inspiration technique (EIT) or end of expiration (EET) technique and the rate of recurrent pneumothorax (RPTX) following removal was compared. We hypothesized that there is no difference in the rate of RPTX between the end inspiratory (EI) and end expiratory (EE) removal technique.

RESULTS

A total 347 patients were included. Of the 184 TTs removed by EIT, there were 17 (9%) RPTXs. Of the 163 with EET, there were 11 RPTXs (7%), (9% versus 7%, chi-squared, P = 0.395). Of the total 28 (9%) patients with RPTXs following removal of chest tubes, two (7%) required reinsertion of chest tube (0.5% (1/184) in EIT and 0.6% (1/163) in EET, P = 0.747).

CONCLUSIONS

Timing of TT removal in relation to the respiratory cycle does not appear to influence the incidence of RPTX in patients with thoracic stab wounds. Technique of removal may well be a more important consideration and more attention must be focused on refining the optimal technique.

Adverse events related to thoracentesis and chest tube insertion: evaluation of the national collection of subject safety incidents in Japan

PURPOSE

Thoracentesis and chest tube insertion are procedures commonly performed in routine clinical practice and are considered mandatory skills for all physicians. Adverse events secondary to these procedures have been widely reported; however, epidemiology data concerning life-threatening events associated with these procedures are lacking.

METHODS

We retrospectively analyzed data from the Japan Council for Quality Health Care open database regarding subject safety incidents involving thoracentesis and chest tube insertion. The adverse events extracted from the database included only events associated with thoracentesis and chest tube insertion reported between January 2010 and April 2020.

RESULTS

We identified 137 adverse events due to thoracentesis or chest tube insertion. Our analysis also revealed at least 15 fatal adverse events and 17 cases of left/right misalignment. Not only resident doctors but also physicians with 10 years or more of clinical experience had been mentioned in these reports. The most common complications due to adverse events were lung injury (55%), thoracic vascular injury (21%), and liver injury (10%). Surgical treatment was required for 43 (31%) of the 137 cases, and the mortality risk was significantly higher for thoracic vascular injury than for other complications (p = 0.02).

CONCLUSION

We identified at least 15 fatal adverse events and 17 cases of left/right misalignment over a 10-year period in the Japan Council for Quality Health Care open database. Our findings also suggest that care should be taken to avoid thoracic vascular injury during chest tube insertion and that immediate intervention is required should such an injury occur.

Surface anatomy site for thoracostomy using the axillary hairline

Objective

Procedural complication rates associated with tube thoracostomy for pleural decompression is estimated to be between 2 and 25%, with incorrect insertion site being a common problem. We hypothesised that the inferior-most hair follicle in the axillary region would provide an accurate biometric marker to identify the fourth to sixth intercostal space.

Methods

A prospective cohort of patients requiring computed tomography scan of the chest was recruited from February 2015 to March 2016 at The Alfred Hospital. The inferior-most hair follicle on the patient’s axillary region was tagged with a paperclip, and a radiologist reported this location with reference to the corresponding intercostal spaces.

Results

Of the 254 enrolled patients, a total of 310 paperclip positions over intercostal spaces were analysed. There were 101 (32.5%) paperclips positioned in the fourth and fifth intercostal spaces with the remainder at the second or third intercostal spaces, and no paperclips placed at the sixth intercostal space or lower.

Conclusions

This study demonstrated that the inferior-most hair follicle in the axilla corresponded to an area between the second and fifth intercostal spaces. Recognition of this surface anatomy has the potential to eliminate iatrogenic injuries to the diaphragm and sub-diaphragmatic organs, but should not be used as the sole marker due to potential risks from high placement of pleural drains.

Intercostal vessel screening prior to pleural interventions by the respiratory physician: a prospective study of real world practice

INTRODUCTION

The rising incidence of pleural disease is seeing an international growth of pleural services, with physicians performing an ever-increasing volume of pleural interventions. These are frequently conducted at sites without immediate access to thoracic surgery or interventional radiology and serious complications such as pleural bleeding are likely to be under-reported.

AIM

To assess whether intercostal vessel screening can be performed by respiratory physicians at the time of pleural intervention, as an additional step that could potentially enhance safe practice.

METHODS

This was a prospective, observational study of 596 ultrasound-guided pleural procedures conducted by respiratory physicians and trainees in a tertiary centre. Operators did not have additional formal radiology training. Intercostal vessel screening was performed using a low frequency probe and the colour Doppler feature.

RESULTS

The intercostal vessels were screened in 95% of procedures and the intercostal artery (ICA) was successfully identified in 53% of cases. Screening resulted in an overall site alteration rate of 16% in all procedures, which increased to 30% when the ICA was successfully identified. This resulted in procedure abandonment in 2% of cases due to absence of a suitable entry site. Intercostal vessel screening was shown to be of particular value in the context of image-guided pleural biopsy.

CONCLUSION

Intercostal vessel screening is a simple and potentially important additional step that can be performed by respiratory physicians at the time of pleural intervention without advanced ultrasound expertise. Whether the widespread use of this technique can improve safety requires further evaluation in a multi-centre setting with a robust prospective study.

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

OBJECTIVE

Thoracic trauma is a leading cause of paediatric trauma deaths. Traumatic cardiac arrest, tension pneumothorax and massive haemothorax are life-threatening conditions requiring emergency and definitive pleural decompression. In adults, thoracostomy is increasingly preferred over needle thoracocentesis for emergency pleural decompression. The present study reports on the early experience of thoracostomy in children, to inform debate regarding the best approach for emergency pleural compression in paediatric trauma.

METHODS

Retrospective review of Ambulance Victoria and The Royal Children's Hospital Melbourne, Trauma Registry between August 2016 and February 2019 to identify children undergoing thoracostomy for trauma, either pre-hospital or in the ED.

RESULTS

Fourteen children aged 1.2-15 years underwent 23 thoracostomy procedures over the 31 month period. The majority of patients sustained transport-related injuries, and underwent thoracostomies for the primary indications of hypoxia and hypotension. Two children were in traumatic cardiac arrest. Ten children underwent needle thoracocentesis prior to thoracostomy, but all required thoracostomy to achieve the necessary definitive decompression. All patients were severely injured with multiple-associated serious injuries and median Injury Severity Score 35.5 (17-75), three of whom died from their injuries. Thoracostomy in our cohort had a low complication rate.

CONCLUSION

In severely injured children, thoracostomy is an effective and reliable method to achieve emergency pleural decompression, including in the young child. The technical challenges presented by children are real, but can be addressed by training to support a low complication rate. We recommend thoracostomy over needle thoracocentesis as the first-line intervention in children with traumatic cardiac arrest, tension pneumothorax and massive haemothorax. [Correction added on 23 September 2019 after first online publication: in the second sentence of the conclusion, the words "under review process" were mistakenly added and have been removed.].

Rule of 4's: Safe and effective pleural decompression and chest drain insertion in severely injured children

The intersecting scenarios of multi-trauma, thoracic injury and traumatic cardiac arrest present some of the most demanding moments in paediatric trauma. For these reasons, decision support through teamwork, checklists, technology and guidelines are central to ensuring quality paediatric trauma care. The 'Rule of 4's' is a simple aide-memoire, which guides clinicians of all grades, expertise and distractedness in a reliable approach to injured children who require safe and effective emergency pleural decompression and timely insertion of a chest drain. The Rule of 4's enables these important therapeutic goals to be met through: (i) four steps in a 'good plan'; (ii) fourth (or fifth) intercostal space as the basis for siting a 'good hole'; (iii) 4× uncuffed endotracheal tube size (4× [age/4 + 4]) to guide selection of a 'good tube'; and (iv) 4 cm mark for a 'good stop' to ensure the drain is in far enough but not too far.

Iatrogenic emergency medicine procedure complications and associated trouble-shooting strategies

PURPOSE

The purpose of this paper is to provide a consolidated reference for the acute management of selected iatrogenic procedural injuries occurring in the emergency department (ED).

DESIGN/METHODOLOGY/APPROACH

A literature search was performed utilizing PubMed, Scopus, Web of Science and Google Scholar for studies through March of 2017 investigating search terms "iatrogenic procedure complications," "error management" and "procedure complications," in addition to the search terms reflecting case reports involving the eight below listed procedure complications.

FINDINGS

This may be particularly helpful to academic faculty who supervise physicians in training who present a higher risk to cause such injuries.

ORIGINALITY/VALUE

Emergent procedures performed in the ED present a higher risk for iatrogenic injury than in more controlled settings. Many physicians are taught error-avoidance rather than how to handle errors when learning procedures. There is currently very limited literature on the error management of iatrogenic procedure complications in the ED.

An Analysis of Patients who Underwent Tube Thoracostomy in the Emergency Department: A Single Center Study

OBJECTIVES

The aim of this study was to determine the demographic and clinical characteristics of patients who underwent tube thoracostomy in the emergency department (ED). The secondary aim of the study was to evaluate parameters such as the diagnosis for which the patients underwent tube thoracostomy, the imaging techniques used during diagnosis, and complications related to the procedure.

MATERIALS AND METHODS

This prospective study was conducted in the ED between June 1, 2015 and May 31, 2016. The study included 125 patients aged >18 years, of both sexes, who presented to the ED during this period and who underwent tube thoracostomy.

RESULTS

The patients comprised 91 (73%) males and 34 (27%) females. Of the 125 patients, 21 (17%) presented directly to the ED, 8 (6%) were referred from a polyclinic, 82 (66%) were brought by ambulance, and 14 (11%) were referred from another center. Reasons for presentation were traumatic in 64 (51%) and non-traumatic in 61 (49%) patients. The leading diagnosis was pneumothorax in 98 (78.4%) cases. The procedure of tube thoracostomy was performed by an emergency medicine (EM) resident for 26 (21%) cases and by a thoracic surgery resident for 99 (79%) cases. Complications were observed at the rate of 3.8% in the procedures performed by the EM residents and at 4% in those performed by the thoracic surgery residents. The mean follow-up time of the patients with tube thoracostomy was 7.5±4.4 days.

CONCLUSION

In intensive trauma centers, in particular, and in centers where procedures such as central venous catheterization and diagnostic thoracentesis are frequently performed, it would be useful for EM physicians to undergo training in performing tube thoracostomy to a level where they are able to intervene in an emergency situation such as traumatic or iatrogenic pneumothorax.

External Validation of a Tube Thoracostomy Complication Classification System

BACKGROUND

Tube thoracostomy (TT) is a commonly performed procedure which is associated with significant complication rates. Currently, there is no validated taxonomy to classify and compare TT complications across different populations. This study aims to validate such TT complication taxonomy in a cohort of South African trauma patients.

METHODS

Post hoc analysis of a prospectively collected trauma database from Pietermaritzburg Metropolitan Trauma Service (PMTS) in South Africa was performed for the period January 2010 to December 2013. Baseline demographics, mechanism of injury and complications were collected and categorized according to published classification protocols. All patients requiring bedside TT were included in the study. Patients who necessitated operatively placed or image-guided TT insertion were excluded. Summary and univariate analyses were performed.

RESULTS

A total of 1010 patients underwent TT. The mean age was (±SD) of 26 ± 8 years. Unilateral TTs were inserted in n = 966 (96%) and bilateral in n = 44 (4%). Complications developed in 162 (16%) patients. Penetrating injury was associated with lower complication rate (11%) than blunt injury (26%), p = 0.0001. Higher complication rate was seen in TT placed by interns (17%) compared to TT placed by residents (7%), p = 0.0001. Complications were classified as: insertional (38%), positional (44%), removal (9%), infective/immunologic (9%), and instructional, educational or equipment related (0%).

CONCLUSIONS

Despite being developed in the USA, this classification system is robust and was able to comprehensively assign and categorize all the complications of TT in this South African trauma cohort. A universal standardized definition and classification system permits equitable comparisons of complication rates. The use of this classification taxonomy may help develop strategies to improve TT placement techniques and reduce the complications associated with the procedure.

LEVEL OF EVIDENCE

V.

STUDY TYPE

Single Institution Retrospective review.

Successful Balloon-Assisted Hepatic Tract Embolization Using the Pull-Through Technique to Remove a Malpositioned Chest Tube Penetrating the Liver and into the Right Ventricle

Intra-abdominal injury is an uncommon complication of chest tube insertion. A 66-year-old man had empyema and underwent chest tube insertion for drainage. Massive hemorrhage occurred; the postprocedural radiograph showed the malpositioned chest tube in the mediastinum. Computed tomography scan showed that the tube's tip penetrated through the liver capsule and passed through the hepatic vein to the right ventricle. Hepatic tract embolization with coiling was performed during chest tube removal under a controlled condition with the hepatic tract occluded by a balloon catheter. The balloon catheter was placed from the right jugular vein using the pull-through technique, establishing a through-and-through guidewire. This is the first report of successful removal of a chest tube malpositioned in the hepatic vein by balloon-assisted hepatic tract embolization without complication.

Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP)

Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the ‘safe zone’ of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation.

Visually guided tube thoracostomy insertion comparison to standard of care in a large animal model

INTRODUCTION

Tube thoracostomy (TT) is a lifesaving procedure for a variety of thoracic pathologies. The most commonly utilized method for placement involves open dissection and blind insertion. Image guided placement is commonly utilized but is limited by an inability to see distal placement location. Unfortunately, TT is not without complications. We aim to demonstrate the feasibility of a disposable device to allow for visually directed TT placement compared to the standard of care in a large animal model.

METHODS

Three swine were sequentially orotracheally intubated and anesthetized. TT was conducted utilizing a novel visualization device, tube thoracostomy visual trocar (TTVT) and standard of care (open technique). Position of the TT in the chest cavity were recorded using direct thoracoscopic inspection and radiographic imaging with the operator blinded to results. Complications were evaluated using a validated complication grading system. Standard descriptive statistical analyses were performed.

RESULTS

Thirty TT were placed, 15 using TTVT technique, 15 using standard of care open technique. All of the TT placed using TTVT were without complication and in optimal position. Conversely, 27% of TT placed using standard of care open technique resulted in complications. Necropsy revealed no injury to intrathoracic organs.

CONCLUSION

Visual directed TT placement using TTVT is feasible and non-inferior to the standard of care in a large animal model. This improvement in instrumentation has the potential to greatly improve the safety of TT. Further study in humans is required.

LEVEL OF EVIDENCE

Therapeutic Level II.

Thoracic Trauma: Which Chest Tube When and Where?

Clinical suspicion of hemo/pneumothorax: when in doubt, drain the chest. Stable chest trauma with hemo/pneumothorax: drain and wait. Unstable patient with dislocated trachea must be approached with drain in hand and scalpel ready. Massive hemo/pneumothorax may be controlled by drainage alone. The surgeon should not hesitate to open the chest if too much blood drains over a short period. The chest drainage procedure does not end with the last stitch; the second half of the match is still ahead. The drained patient is in need of physiotherapy and proper pain relief with an extended pleural space: control the suction system.

Iatrogenic splenic injury: review of the literature and medico-legal issues

INTRODUCTION

Iatrogenic splenic injury is a recognized complication in abdominal surgery. The aim of this paper is to understand the medico-legal issues of iatrogenic splenic injuries. We performed a literature review on PubMed and Scopus using iatrogenic splenic or spleen injury and iatrogenic splenic rupture as keywords. Iatrogenic splenic injury cases were identified. Most cases were related to colonoscopy, but we also identified cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. There are several surgical procedures that can lead to a splenic injury. However, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than being an unpredictable and unpreventable complication. It is important for the medico-legal expert to have great knowledge on iatrogenic splenic injuries because it is important to evaluate every step of the first procedure performed, how a splenic injury is produced, and whether the correct treatment for the splenic injury was administered in a judgment.

Correlation between ATLS training and junior doctors' anatomical knowledge of intercostal chest drain insertion

OBJECTIVE

To review the ability of junior doctors (JDs) in identifying the correct anatomical site for intercostal chest drain insertion and whether prior Advanced Trauma Life Support (ATLS) training influences this.

DESIGN

We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact preferred site for intercostal chest drain insertion.

SETTING

This study was conducted in a large metropolitan university hospital in South Africa.

RESULTS

A total of 152 JDs participated in the study. Among them, 63 (41%) were men, and the mean age was 24 years. There were 90 (59%) PGY1 doctors and 62 (41%) PGY2 doctors. Overall, 28% (42/152) of all JDs correctly identified the site that was located within the accepted safe triangle. A significantly higher proportion of PGY2 doctors selected the correct site when compared with PGY1 doctors (39% vs 20%, p = 0.026). Those who had prior ATLS provider training were 6.8 times more likely to be able to identify the correct site (RR = 6.8, 95% CI: 3.7-12.5).

CONCLUSIONS

Most of the JDs do not have sufficient anatomical knowledge to identify the safe insertion site for intercostal chest drain. Those who had undergone ATLS training were more likely to be able to identify the safe insertion site.

Prophylactic antibiotics for tube thoracostomy may not be appropriate in the developing world setting

INTRODUCTION

Prophylactic antibiotics for tube thoracostomy (TT) for the prevention of post-traumatic empyema (PTE) remain controversial. Literature specifically focusing on the developing world setting is limited.

MATERIALS AND METHODS

A retrospective study was conducted over a four-year period on patients managed with TT alone in which prophylactic antibiotics was not utilised. We documented the actual incidence of PTE in a high volume trauma service in South Africa.

RESULTS

A total of 1002 patients who had TT in the trauma room were eligible for inclusion. Ninety-one percent (912/1002) were males and the mean age for all patients was 26 years (SD 7). Seventy-five percent (755/1002) sustained penetrating trauma (PT), while the remaining 25% (247/1002) sustained blunt trauma (BT). Six hundred and twenty patients (62%) sustained HTXs and the remaining 382 patients (38%) had PTXs. Of the 1002 patients who underwent TT, 15 (1.5%, 95% CI: 0.8-2.5%) developed PTE. The incidence of empyema in those with PT was 1.9% (14/755) and 0.4% (1/247) for BT. This difference was not statistically significant (p=0.166). All 15 patients who developed PTE were males, with a mean age of 31 years (SD 6). All 15 patients had HTX as the initial thoracic pathology. This difference was highly statistically significant when compared to PTX (p=0.002). The mean length of hospital stay was 11 days (SD 7). There were no mortalities in these patients.

CONCLUSIONS

In our setting where prophylactic antibiotics are not routinely used, the actual incidence of PTE in our population is extremely low. In the absence of further definitive evidence to support its use, routine prophylactic antibiotics for TT is difficult to justify in a developing world setting at present.