Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial

Time to resolution of radiologically detected hemothorax in trauma patients: A retrospective observational study

BACKGROUND

Traumatic hemothorax is a common complication of chest trauma; however, the timeline for its resolution, even with chest tube thoracostomy, remains unclear.

AIM

To determine the time to resolution of the hemothorax to ensure safe discharge based on chest radiography (CXR) findings.

METHODS

A retrospective observational study was conducted at Hamad General Hospital, Qatar, from June 2014 to October 2019, including all patients with hemothorax diagnosed via computed tomography (CT) following chest trauma. Based on the initial imaging study, the hemothorax was divided into right, left, and bilateral.

RESULTS

The study included 422 patients. Of the total, 57.82% (n = 244/422) resolved their hemothorax within three days of admission. Among these, 44 patients required chest tube insertion (CTI) and 200 were cleared without it. Between days 3 and 7, an additional 16.83% (n = 71 /422) of cases were resolved, of which 28 required chest tubes. By days 8 to 14, another 11.37% (n = 48/422) were cleared, with 15 patients requiring chest tubes. After 14 days, 13.98% (n = 59/422) of patients still had hemothorax, 14 of whom required CTI.

CONCLUSION

This study showed that a subset of patients continued to experience retained hemothorax despite early tube thoracostomy. Patients with a larger hemothorax, particularly on the left side, showed prolonged resolution times. Regular imaging such as CXR or CT is recommended for up to 14 days post-intervention. After this period, outpatient follow-up is generally safe, although some patients may still have a persistent hemothorax beyond two weeks.

A Randomized Non-Inferiority Clinical Trial of 14Fr Thal versus 28Fr Tube Thoracostomy for Traumatic Hemothorax

BackgroundThe traditional treatment of traumatic hemothorax (HTX) is large bore chest tubes (CT) ≥28Fr. Recent evidence shows 14Fr pigtail catheters are as effective in drainage of HTX as larger CT. However, this has not been shown in 14Fr Thal tubes, a straight chest tube placed utilizing Seldinger technique.MethodsA single center, prospective randomized controlled trial was performed at an ACS verified Level 1 trauma center comparing 14Fr Thal CT (14CT) to 28Fr CT (28CT) between May 2017 and September 2021. The primary outcome was failure of drainage of hemothorax requiring additional intervention. Secondary outcomes included duration of chest tube placement, length of stay, tube-specific complications, and 90-day hospital readmission. Farrington-Manning approach was used for non-inferiority tests. Wilcoxon 2-samples test or t test was used for continuous variables, and Pearson chi-square or Fisher exact test was used for categorical variables.Results109 patients were included in the randomized trial. There were 54 patients in the 14CT cohort, and 55 patients in the 28CT cohort. The primary outcome of drainage failure was similar between groups (8.3% 14CT vs 3.9% 28CT). Using a 15% non-inferiority margin 14CT is non-inferior to 28CT. No differences were identified in secondary outcomes.Conclusion14Fr Thal tubes have similar efficacy in drainage of traumatic hemothorax when compared with 28Fr chest tubes with similar complication rates (NCT03167723).

Thoracic irrigation for traumatic hemothorax: A systematic review and meta-analysis

BACKGROUND

Traumatic hemothoraces (HTXs) are common, and tube thoracostomy (TT) insertion is generally the initial management. However, a retained HTX can develop into a fibrothorax or empyema requiring secondary intervention. We hypothesized that irrigation of the thoracic cavity at the time of TT may prevent retained HTX.

METHODS

Pubmed, EMBASE, and Scopus were searched from inception to May 2024. Studies with adult trauma patients with traumatic HTX who received a TT and had patients who underwent thoracic irrigation were included. The primary outcome was failure rate, defined as retained HTX requiring a second intervention. Cumulative analysis was performed with χ 2 for dichotomous variables and unpaired t test for continuous variables. A fixed-effects model was applied for meta-analysis.

RESULTS

Six studies were included in the analysis; two retrospective and four prospective observational studies. These studies included 1,319 patients (513 irrigated TT, 837 nonirrigated TT). The mean age of patients was 45 years, 81% were male, mean Injury Severity Score was 21, and 42% had penetrating trauma. Failure rate was significantly lower in the irrigation group on cumulative analysis (10.7% vs. 18.2%, p < 0.001) and meta-analysis (effect size, 0.704; 95% confidence interval, 0.218-1.190; I2 = 0.4; p < 0.001]. In addition, on meta-analysis, the irrigation group had a shorter TT duration and hospital and ICU length of stay (all p < 0.05). There were no differences in overall infectious complications, readmission, or mortality; however, all the models favored the irrigation group.

CONCLUSION

Patients who undergo simultaneous TT and thoracic irrigation have a lower rate of retained HTX and require fewer secondary interventions. Thoracic irrigation for traumatic HTX should be considered; however, randomized studies are needed prior to development of guidelines.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level III.

Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multicenter study

BACKGROUND

Retained hemothorax (rHTX) requiring intervention occurs in up to 20% of patients who undergo chest tube (TT) placement for a hemothorax (HTX). Thoracic irrigation at the time of TT placement decreases the need for secondary intervention in this patient group but those findings are limited because of the single-center design. A multicenter study was conducted to evaluate the effectiveness of thoracic irrigation.

METHODS

A multicenter, prospective, observational study was conducted between June 2018 and July 2023. Eleven sites contributed patients. Patients were included if they had a TT placed for a HTX and were excluded if: younger than 18 years, TT for pneumothorax, thoracotomy or video-assisted thoracoscopic surgery performed within 6 hours of TT, TT >24 hours after injury, TT removed <24 hours, or death within 48 hours. Thoracic irrigation was performed at the discretion of the attending. Each hemithorax was considered separately if bilateral HTX. The primary outcome was secondary intervention for HTX-related complications (rHTX, effusion, or empyema). Secondary intervention was defined as: TT placement, instillation of thrombolytics, video-assisted thoracoscopic surgery, or thoracotomy. Irrigated and nonirrigated hemithoraces were compared using a propensity weighted analysis with age, sex, mechanism of injury, Abbreviated Injury Scale chest, and TT size as predictors.

RESULTS

Four hundred ninety-three patients with 462 treated hemothoraces were included, 123 (25%) had thoracic irrigation at TT placement. There were no significant demographic differences between the cohorts. Fifty-seven secondary interventions were performed, 10 (8%) and 47 (13%) in the irrigated and non-irrigated groups, respectively ( p = 0.015). Propensity weighted analysis demonstrated a reduction in secondary interventions in the irrigated cohort (odds ratio, 0.56 (0.34-0.85); p = 0.005).

CONCLUSION

This Western Trauma Association multicenter study demonstrates a benefit of thoracic irrigation at the time of TT placement for a HTX. Thoracic irrigation reduces the odds of a secondary intervention for rHTX-related complications by 44%.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

The role of video-assisted thoracoscopy in chest trauma: a retrospective monocentric experience

Video-assisted thoracoscopy (VAT) plays an essential role in the exploration of pleural cavity after thoracic trauma, although some doubts about the precise and specific indications persist. This study examines the eligibility criteria for videothoracoscopy and establishes the ideal timing for VAT. Between January 2011 and November 2022, we observed 923 polytraumatized patients. All patients underwent computed tomography (CT) scan total body with and without contrast enhancement. Two hundred and nine patients carried out VAT within 10 ± 2 h of injury while 8 patients after 20 ± 1 h. The Injury Severity Score (ISS) was 31 ± 1 and the Glasgow Coma Scale was 14.1 ± 0.3 upon arrival at the hospital. One hundred and nineteen patients displayed hemothorax (55%), 62 hemopneumothorax (28.5%), 21 penetrating wound (9.6%), 10 pneumothorax (4.6%) and 5 chylothorax (2.3%). In 18 patients (8.3%) without vascular, diaphragmatic, or parenchymal lesion the treatment consisted in chest tube placement. VAT was converted to video-assisted thoracoscopic surgery (VATS) in 190 patients (87.5%), to open surgery in 8 (3.7%) and to laparoscopy in 1 (0.5%). Twelve patients (5.5%) with diaphragm ruptures < 5 cm in diameter were treated by separate stitches suture in VATS. Only eight postoperative complications (4 pneumonia, three atelectasis and one pulmonary embolism) out of 217 VAT, positively resolved with medical treatment, were noted exclusively in patients undergoing minimally invasive approach 20 ± 1 h after trauma. Early VAT in selected patients is a safe and easy procedure that ensure a quick diagnosis of lesions and an accurate management of the most thoracic injuries among trauma patients. The prompt identification of injuries, to avoid life-threatening conditions requiring rapid intervention, responds to medico-legal needs to which VAT fulfills.

Thoracic cavity irrigation prevents retained hemothorax and decreases surgical intervention in trauma patients

INTRODUCTION

Retained hemothorax (HTX) is a common complication following thoracic trauma. Small studies demonstrate the benefit of thoracic cavity irrigation at the time of tube thoracostomy (TT) for the prevention of retained HTX. We sought to assess the effectiveness of chest irrigation in preventing retained HTX leading to a secondary surgical intervention.

METHODS

We performed a single-center retrospective study from 2017 to 2021 at a Level I trauma center, comparing bedside thoracic cavity irrigation via TT versus no irrigation. Using the trauma registry, patients with traumatic HTX were identified. Exclusion criteria were TT placement at an outside hospital, no TT within 24 hours of admission, thoracotomy or video-assisted thoracoscopic surgery (VATS) prior to or within 6 hours after TT placement, VATS as part of rib fixation or diaphragmatic repair, and death within 96 hours of admission. Bivariate and multivariable analyses were conducted.

RESULTS

A total of 370 patients met the inclusion criteria, of whom 225 (61%) were irrigated. Patients who were irrigated were more likely to suffer a penetrating injury (41% vs. 30%, p = 0.03) and less likely to have a flail chest (10% vs. 21%, p = 0.01). On bivariate analysis, irrigation was associated with lower rates of VATS (6% vs. 19%, p < 0.001) and retained HTX (10% vs. 21%, p < 0.001). The irrigated cohort had a shorter TT duration (4 vs. 6 days, p < 0.001) and hospital length of stay (7 vs. 9 days, p = 0.04). On multivariable analysis, thoracic cavity irrigation had lower odds of VATS (adjusted odds ratio, 0.37; 95% confidence interval [CI], 0.30-0.54), retained HTX (adjusted odds ratio, 0.42; 95% CI, 0.25-0.74), and a shorter TT duration ( β = -1.58; 95% CI, -2.52 to -0.75).

CONCLUSION

Our 5-year experience with thoracic irrigation confirms findings from smaller studies that irrigation prevents retained HTX and decreases the need for surgical intervention.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Thoracic Lavage for Traumatic Hemothorax

This Surgical Innovation discusses thoracic lavage for traumatic hemothorax.

Chest Tube Size Selection: Evaluating Provider Practices, Treatment Efficacy, and Complications in Management of Thoracic Trauma

BACKGROUND

The standard for managing traumatic pneumothorax (PTX), hemothorax (HTX), and hemopneumothorax (HPTX) has historically been large-bore (LB) chest tubes (>20-Fr). Previous studies have shown equal efficacy of small-bore (SB) chest tubes (≤19-Fr) in draining PTX and HTX/HPTX. This study aimed to evaluate provider practice patterns, treatment efficacy, and complications related to the selection of chest tube sizes for patients with thoracic trauma.

METHODS

A retrospective chart review was performed on adult patients who underwent tube thoracostomy for traumatic PTX, HTX, or HPTX at a Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between SB and LB thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern. Secondary outcomes included retained hemothorax, insertion-related complications, and duration of chest tube placement. Univariate and multivariate analyses were performed.

RESULTS

Three hundred and forty-one patients were included and 297 (87.1%) received LB tubes. No significant differences were found between the groups concerning tube failure and insertion-related complications. LB tubes were more frequently placed in patients with penetrating MOI, higher average ISS, and higher average thoracic AIS. Patients who received LB chest tubes experienced a higher incidence of retained HTX.

DISCUSSION

In patients with thoracic trauma, both SB and LB chest tubes may be used for treatment. SB tubes are typically placed in nonemergent situations, and there is apparent provider bias for LB tubes. A future randomized clinical trial is needed to provide additional data on the usage of SB tubes in emergent situations.

Management of Blunt Chest Trauma

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

Outcomes of Video-assisted Thoracic Surgery-guided Early Evacuation of Traumatic Hemothorax: A Randomized Pilot Study at Level I Trauma Center

Introduction

Traumatic hemothorax is accounted for about 20% of traumatic chest injuries. Although majority can be managed with the timely placement of intercostal tube (ICT) drainage, the remaining pose a challenge owing to high complication rates associated with retained hemothorax. Although various treatment modalities including intrapleural instillation of fibrinolytics, radioimage guided drainage, VATS guided evacuation and thoractomy do exist to address the retained hemothorax, but indications along with timing to employ a specific treatment option is still unclear and ambiguous.

Methods

Patient with residual hemothorax (>200 mL) on ultrasonography after 48 h of indwelling ICT was randomized into either early video-assisted thoracic surgery (VATS) or conventional approach cohort. Early VATS cohort was subjected to video-assisted thoracoscopic evacuation of undrained blood along with normal saline irrigation and ICT placement. The conventional cohort underwent intrapleural thrombolytic instillation for 3 consecutive days. The outcome measures were the duration of indwelling ICT, removal rate of tube thoracostomy, length of hospital stay, duration of intensive care unit (ICU) monitoring, need for mechanical ventilation, incidence of pulmonary and pleural complications, and requirement of additional intervention to address undrained hemothorax and mortality rate.

Results

The early VATS cohort had shorter length of hospital stay (7.50 ± 0.85 vs. 9.50 ± 3.03, P = 0.060), reduced duration of indwelling ICT (6.70 ± 1.25 vs. 8.30 ± 2.91, P = 0.127) with higher rate of tube thoracostomy removal (70% vs. 30%, P = 0.003) and lesser need of additional interventions (0% vs. 30%, P = 0.105). Thoracotomy (3 patients) and image-guided drainage (4 patients) were additional interventions to address retained hemothorax in the conventional cohort. However, similar length of ventilator assistance (0.7 ± 0.48 vs. 0.60 ± 1.08, P = 0.791) and prolonged ICU monitoring (1.30 ± 1.06 vs. 0.90 ± 1.45, P = 0.490) was observed in early VATS cohort. Both the cohorts had no mortality.

Conclusion

VATS-guided early evacuation of traumatic hemothorax is associated with shorter length of hospital stay along with abbreviated indwelling ICT duration, reduced incidence of complications, lesser readmissions, and improved rate of tube thoracostomy removal. However, the duration of ventilator requirement, ICU stay, and mortality remain unchanged.

Percutaneous thoracostomy with thoracic lavage for traumatic hemothorax: a performance improvement initiative

Objectives

Percutaneously placed small-bore (14 Fr) catheters and pleural lavage have emerged independently as innovative approaches to hemothorax management. This report describes techniques for combining percutaneous thoracostomy with pleural lavage and presents results from a performance improvement series of patients managed with percutaneous thoracostomy with immediate lavage.

Methods

This was a prospective performance improvement series of patients treated at a level 1 trauma center with percutaneous thoracostomy and immediate lavage between April 2021 and May 2023.

Results

Percutaneous thoracostomy with immediate lavage was used to treat nine hemodynamically normal patients with acute hemothorax. Injuries included both blunt and penetrating mechanisms. 56% of patients presented immediately after injury, and 44% presented in a delayed fashion ranging from 2 to 26 days after injury. Median length of stay was 6 days (IQR 6, 9). Seven patients were discharged home in stable condition, one was discharged to an acute rehabilitation facility, and one was discharged to a skilled nursing facility.

Conclusions

Percutaneous thoracostomy with pleural lavage is clinically feasible and effective and warrants further evaluation with a multicenter clinical trial.

Level of evidence

Therapeutic/care management, level V.

CT-based pleural effusion volume estimation formula demonstrates low accuracy and reproducibility for traumatic hemothorax

PURPOSE

We aimed to evaluate the accuracy and reproducibility of the CT-based volume estimation formula V = d2 * h, where d and h represent the maximum depth and height of the effusion, for acute traumatic hemothorax.

MATERIALS & METHODS

Prospectively identified patients with CT showing acute traumatic hemothorax were considered. Volumes were retrospectively estimated using d2 * h, then manually measured on axial images. Subgroup analysis was performed on borderline-sized hemothorax (200-400 mL). Measurements were repeated by three non-radiologists. Bland-Altman analysis was used to assess agreement between the two methods and agreement between raters for each method.

RESULTS

A total of 46 patients (median age 34; 36 men) with hemothorax volume 23-1622 mL (median 191 mL, IQR 99-324 mL) were evaluated. Limits of agreement between estimates and measured volumes were -718 - +842 mL (± 202 mL). Borderline-sized hemothorax (n = 13) limits of agreement were -300 - +121 mL (± 114 mL). Of all hemothorax, 85 % (n = 39/46) were correctly stratified as over or under 300 mL, and of borderline-sized hemothorax, 54 % (n = 7/13). Inter-rater limits of agreement were -251 - +350, -694 - +1019, and -696 - +957 for the estimation formula, respectively, and -124 - +190, -97 - +111, and -96 - +46 for the measured volume.

DISCUSSION

An estimation formula varies with actual hemothorax volume by hundreds of mL. There is low accuracy in stratifying hemothorax volumes close to 300 mL. Variability between raters was substantially higher with the estimation formula than with manual measurements.

A Novel Rabbit Model of Retained Hemothorax with Pleural Organization

Retained hemothorax (RH) is a commonly encountered and potentially severe complication of intrapleural bleeding that can organize with lung restriction. Early surgical intervention and intrapleural fibrinolytic therapy have been advocated. However, the lack of a reliable, cost-effective model amenable to interventional testing has hampered our understanding of the role of pharmacological interventions in RH management. Here, we report the development of a new RH model in rabbits. RH was induced by sequential administration of up to three doses of recalcified citrated homologous rabbit donor blood plus thrombin via a chest tube. RH at 4, 7, and 10 days post-induction (RH4, RH7, and RH10, respectively) was characterized by clot retention, intrapleural organization, and increased pleural rind, similar to that of clinical RH. Clinical imaging techniques such as ultrasonography and computed tomography (CT) revealed the dynamic formation and resorption of intrapleural clots over time and the resulting lung restriction. RH7 and RH10 were evaluated in young (3 mo) animals of both sexes. The RH7 recapitulated the most clinically relevant RH attributes; therefore, we used this model further to evaluate the effect of age on RH development. Sanguineous pleural fluids (PFs) in the model were generally small and variably detected among different models. The rabbit model PFs exhibited a proinflammatory response reminiscent of human hemothorax PFs. Overall, RH7 results in the consistent formation of durable intrapleural clots, pleural adhesions, pleural thickening, and lung restriction. Protracted chest tube placement over 7 d was achieved, enabling direct intrapleural access for sampling and treatment. The model, particularly RH7, is amenable to testing new intrapleural pharmacologic interventions, including iterations of currently used empirically dosed agents or new candidates designed to safely and more effectively clear RH.

Continued Development and Testing of a Novel Steerable Chest Tube, Extendable Infusion Cannula, and Portable Suction-Infusion Pump for Use in Austere and Transport Environments to Prevent Retained Hemothorax

With blunt and penetrating trauma to the chest, warfighters frequently suffer from hemothorax. Optimal management requires the placement of a chest tube to evacuate the blood. Malposition of the tube may be a causative factor of inadequate drainage (retained hemothorax). As a potential solution, we developed a previously reported steerable chest tube allowing accurate placement into a desired location to enhance effectiveness. To provide assisted aspiration, we developed a portable, battery-operated suction device capable of simultaneous or sequential infusion. This report details the ongoing progress of this project. Updated steerable tube and pump prototypes were designed and produced. The tubes were tested for feasibility in two pigs and one cadaver by fluoroscopically comparing tip positions after insertion by a number of providers. Measured drainage volumes comparing standard vs. steerable tubes after pleural infusion of 1,000 mL of saline in two pigs were compared. Testing of the pump focused on the accuracy of suction and volume functions. The steerable tube prototype consists of sequentially bonded segments of differing flexibility and an ergonomic tensioning handle. The portable suction pump accurately provides up to 80 cmH2O of suction, an infusion capability of up to 10 mL/min, and a 950 mL removable reservoir canister. After minimal training, providers easily and repeatedly placed the tip of the steerable tube in the lateral diaphragmatic sulcus in animals and cadavers. Arc was limited to the distal segment. Compared to a standard tube, the steerable tube placed along the diaphragm improved pleural fluid drainage volumes by 17%, although this did not reach statistical significance in six trials. These new prototypes represent substantial improvements and were performed according to expectations. We believe that this steerable chest tube and portable suction-infusion pump can be effectively used for warfighters with chest injuries in austere environments.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis

BACKGROUND

Traumatic hemothorax is common, and management failure leads to worse outcomes. We sought to determine predictive factors and understand the role of trauma center performance in hemothorax management failure.

METHODS

We prospectively examined initial hemothorax management (observation, pleural drainage, surgery) and failure requiring secondary intervention in 17 trauma centers. We defined hemothorax management failure requiring secondary intervention as thrombolytic administration, tube thoracostomy, image-guided drainage, or surgery after failure of the initial management strategy at the discretion of the treating trauma surgeon. Patient-level predictors of hemothorax management failure requiring secondary intervention were identified for 2 subgroups: initial observation and immediate pleural drainage. Trauma centers were divided into quartiles by hemothorax management failure requiring secondary intervention rate and hierarchical logistic regression quantified variation.

RESULTS

Of 995 hemothoraces in 967 patients, 186 (19%) developed hemothorax management failure requiring secondary intervention. The frequency of hemothorax management failure requiring secondary intervention increased from observation to pleural drainage to surgical intervention (12%, 22%, and 35%, respectively). The number of ribs fractured (odds ratio 1.12 per fracture; 95% confidence interval 1.00-1.26) and pulmonary contusion (odds ratio 2.25, 95% confidence interval 1.03-4.91) predicted hemothorax management failure requiring secondary intervention in the observation subgroup, whereas chest injury severity (odds ratio 1.58; 95% confidence interval 1.17-2.12) and initial hemothorax volume evacuated (odds ratio 1.10 per 100 mL; 95% confidence interval 1.05-1.16) predicted hemothorax management failure requiring secondary intervention after pleural drainage. After adjusting for patient characteristics in the logistic regression model for hemothorax management failure requiring secondary intervention, patients treated at high hemothorax management failure requiring secondary intervention trauma centers were 6 times more likely to undergo an intervention after initial hemothorax management failure than patients treated in low hemothorax management failure requiring secondary intervention trauma centers (odds ratio 6.18, 95% confidence interval 3.41-11.21).

CONCLUSION

Failure of initial management of traumatic hemothorax is common and highly variable across trauma centers. Assessing patient selection for a given management strategy and center-level practices represent opportunities to improve outcomes from traumatic hemothorax.

[Occult and Retained Haemothorax - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Trauma Society (DGU - Section NIS) and the German Society for Thoracic Surgery (DGT)]

The management of occult and retained haemothorax is challenging for all involved in the care of polytrauma patients in terms of diagnosis and treatment. The focus of decision making is preventing sequelae such as pleural empyema and avoiding a trapped lung. An interdisciplinary task force of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU) on thoracic trauma offers recommendations for post-trauma care of patients with occult and/or retained haemothorax, as based on a comprehensive literature review.

Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial

Objective

To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial.

Summary background data

Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined.

Methods

A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage.

Results

A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001).

Conclusion

This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted.

Level of evidence

NA.

Risk Factors for Retained Hemothorax after Trauma: A 10-Years Monocentric Experience from First Level Trauma Center in Italy

Thoracic trauma occurs in 20–25% of all trauma patients worldwide and represents the third cause of trauma-related mortality. Retained hemothorax (RH) is defined as a residual hematic pleural effusion larger than 500 mL after 72 h of treatment with a thoracic tube. The aim of this study is to investigate risk factors for the development of RH in thoracic trauma and predictors of surgery. A retrospective, observational, monocentric study was conducted in a Trauma Hub Hospital in Milan, recording thoracic trauma from January 2011 to December 2020. Pre-hospital peripheric oxygen saturation (SpO₂) was significantly lower in the RH group (94% vs. 97%, p = 0.018). Multivariable logistic regression analysis identified, as independent predictors of RH, sternum fracture (OR 7.96, 95% CI 1.16–54.79; p = 0.035), pre-admission desaturation (OR 0.96; 95% CI 0.77–0.96; p = 0.009) and the number of thoracic tube maintenance days (OR 1.22; 95% CI 1.09–1.37; p = 0.0005). The number of tubes placed and the 1° rib fracture were both significantly associated with the necessity of surgical treatment of RH (2 vs. 1, p = 0.004; 40% vs. 0%; p = 0.001). The risk of developing an RH in thoracic trauma should not be underestimated. Variables related to RH must be taken into account in order to schedule a proper follow-up after trauma.

Optimal time to thoracoscopy for trauma patients with retained hemothorax

BACKGROUND

Retained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set.

METHODS

Patients undergoing VATS for retained hemothorax within the first 14 days postinjury were identified from the Trauma Quality Improvement Program database over 5 years, ending in 2016. Demographics, mechanism, severity of injury, severity of shock, time to VATS, pulmonary morbidity, and mortality were recorded. Multivariable logistic regression analysis was performed to determine independent predictors of pulmonary morbidity. Youden's index was then used to identify the optimal time to VATS.

RESULTS

From the Trauma Quality Improvement Program database, 3,546 patients were identified. Of these, 2,355 (66%) suffered blunt injury. The majority were male (81%) with a median age and Injury Severity Score of 46 and 16, respectively. The median time to VATS was 134 hours. Both pulmonary morbidity (13 vs 17%, P = .004) and hospital length of stay (9 vs 12 days, P < .0001) were significantly reduced in patients undergoing VATS before 3.9 days. Multivariable logistic regression identified VATS during the first 7 days as the only modifiable risk factor significantly associated with reduced pulmonary morbidity (odds ratio 0.52; 95% confidence interval 0.43-0.63, P < .0001).

CONCLUSION

Patients undergoing VATS for retained hemothorax have significant morbidity and prolonged length of stay. VATS within the first week of admission results in fewer pulmonary complications and shorter length of stay. In fact, the optimal time to VATS was identified as 3.9 days and was the only modifiable risk factor associated with decreased pulmonary morbidity.

The Volume of Thoracic Irrigation Is Associated With Length of Stay in Patients With Traumatic Hemothorax

INTRODUCTION

Irrigation of the thoracic cavity at tube thoracostomy (TT) placement may decrease the rate of a retained hemothorax (RHTX); however, other resource utilization outcomes have not yet been quantified. This study evaluated the association of thoracic irrigation during TT with the length of stay and outcomes in patients with traumatic hemothorax (HTX).

METHODS

A retrospective chart review was performed of adult patients receiving a TT for HTX at a single, urban Level 1 Trauma Center from January 2019 to December 2020. Those who underwent irrigation during TT at the discretion of the trauma surgeon were compared to a control of standard TT without irrigation. Death within 30 d, as well as TTs, placed at outside hospitals, during traumatic arrest or thoracic procedures, and for isolated pneumothoraces were excluded. The primary outcome was the length of stay as hospital-free, ICU-free, and ventilator-free days (30-day benchmark). Subgroup analysis by irrigation volume was conducted using one-way ANOVA testing with P < 0.05 considered statistically significant.

RESULTS

Eighty-two (41.4%) of 198 patients underwent irrigation during TT placement. Secondary interventions, thoracic infections, and TT duration were not statistically different in the irrigated cohort. Hospital-free and ICU-free days were higher in the irrigated patients than in the controls. Groups irrigated with ≥1000 mL had significant more hospital-free days (P = 0.007) than those receiving less than 1000 mL.

CONCLUSIONS

Patients with traumatic HTX who underwent thoracic irrigation at the time of TT placement had decreased hospital and ICU days compared to standard TT placement alone. Specifically, our study demonstrated that patients irrigated with a volume of at least 1000 mL had greater hospital-free days compared to those irrigated with less than 1000 mL.

Readmission for pleural space complications after chest wall injury: Who is at risk?

BACKGROUND

Little is known about patient characteristics predicting postdischarge pleural space complications (PDPSCs) after thoracic trauma. We sought to analyze the patient population who required unplanned hospital readmission for PDPSC.

METHODS

Retrospective review of adult patients admitted to a Level I Trauma Center with a chest Abbreviated Injury Scale (AIS) score of 2 or greater between January 2015 and August 2020. Those readmitted within 30 days of index hospitalization discharge for PDPSC were compared with those not readmitted. Demographics, injury characteristics, surgical procedures, imaging, and readmission data were retrieved.

RESULTS

Out of 17,192 trauma evaluations, 3,412 (19.8%) suffered a chest AIS score of 2 or greater injury and 155 experienced an unplanned 30-day hospital readmission. Of those, 49 (1.4%) were readmitted for the management of PDPSC (readmit PDPSC) and were compared with patients who were not readmitted (no readmit, n = 3,257). The readmit PDPSC group was significantly older age, heavier, comprised of fewer men, and suffered a higher mean chest AIS score. The readmit PDPSC group had a significantly higher incidence of rib fractures, flail chest, pneumothorax, hemothorax, scapula fractures, and a higher rate of tube thoracostomy placement during index admission. The discharge chest X-ray in the readmit PDPSC group demonstrated a pleural space abnormality in 36 (73%) of patients. Mean time to readmission was 10.2 (7.2) days, and hospital length of stay on readmission was 5.8 (3.7) days. Pleural effusion was the most common readmission diagnosis (44 [90%]), and 42 (86%) required tube thoracostomy.

CONCLUSION

We describe the subset of chest wall injury patients who require hospital readmission for PDPSC. Characteristics from index hospitalization associated with PDPSC include older age, female sex, heavier weight, presence of rib fractures, pleural space abnormality, scapular fracture, and chest tube placement. Further studies are needed to characterize this at-risk chest wall injury population, and to determine what interventions can facilitate outpatient management of postdischarge pleural space complications and mitigate readmission risk.

LEVEL OF EVIDENCE

Prognostic and epidemiologic, Level IV; Care management, Level V.

The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial

INTRODUCTION

The traditional treatment of traumatic hemothorax (HTX) has been an insertion of a large-bore 36- to 40-Fr chest tube. Our previous single-center randomized controlled trial (RCT) had shown that 14-Fr percutaneous catheters (PCs) (pigtail) were equally as effective as chest tube. We performed a multicenter RCT, hypothesizing that PCs are as equally effective as chest tubes in the management of patients with traumatic HTX (NCT03546764).

METHODS

We performed a multi-institution prospective RCT comparing 14-Fr PCs with 28- to 32-Fr chest tubes in the management of patients with traumatic HTX from July 2015 to September 2020. We excluded patients who were in extremis and required emergent tube placement and those who refused to participate. The primary outcome was failure rate, defined as a retained HTX requiring a second intervention. Secondary outcomes included daily drainage output, tube days, intensive care unit and hospital length of stay, and insertion perception experience (IPE) score on a scale of 1 to 5 (1, tolerable experience; 5, worst experience). Unpaired Student's t test, χ2, and Wilcoxon rank sum test were used with significance set at p < 0.05.

RESULTS

After exclusion, 119 patients participated in the trial, 56 randomized to PCs and 63 to chest tubes. Baseline characteristics between the two groups were similar. The primary outcome, failure rate, was similar between the two groups (11% PCs vs. 13% chest tubes, p = 0.74). All other secondary outcomes were also similar, except PC patients reported lower IPE scores (median, 1: "I can tolerate it"; interquartile range, 1-2) than chest tube patients (median, 3: "It was a bad experience"; interquartile range, 2-5; p < 0.001).

CONCLUSION

Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.

LEVEL OF EVIDENCE

Therapeutic, level II.

Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal

BACKGROUND

Traumatic hemothorax is a common injury that invites diagnostic and management strategy debates. Evidence-based management has been associated with improved care efficiency. However, the literature abounds with long-debated, re-emerging, and new questions. We aimed to consolidate up-to-date evidence on traumatic hemothoraces, focusing on clinical conundra debated in literature.

METHODS

We conducted a scoping review of 21 clinical conundra in traumatic hemothorax diagnosis and management according to PRISMA-ScR guidelines. Experimental and observational studies evaluating patients (aged ≥18 years) with traumatic hemothoraces were identified through database searches (PubMed, EMBASE, Web of Science, Cochrane Library; database inception to Sep, 26 2020) and bibliography reviews of selected articles. Three reviewers screened and selected articles using standardized forms.

RESULTS

We screened 1,440 articles for eligibility, of which 71 met criteria for synthesis. The review comprises 6 sections: (1) Presumptive antibiotics before tube thoracostomy; (2) Initial diagnostic and intervention decisions; (3) Chest tubes; (4) Retained hemothoraces; (5) Delayed hemothoraces; and (6) Chest tube removal). The 21 conundra across these sections follow the format of a question, our recommendation based on interpretation of available evidence, and succinct rationale. Rationale sections detail knowledge gaps and opportunities for future research.

CONCLUSION

Even practices engrained into surgical dogma, such as obtaining chest x-rays after inserting or removing chest tubes and mandating operation for patients who develop chest tube output above a certain threshold, deserve re-evaluation. Some knowledge gaps require rigorous future investigation; sound clinical judgment can likely supplement others.