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Haider S, Kamal MT, Shoaib N, Zahid M. Thoracostomy tube withdrawal during latter phases of expiration or inspiration: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2023; 49:2389-2400. [PMID: 37347296 DOI: 10.1007/s00068-023-02306-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/06/2023] [Indexed: 06/23/2023]
Abstract
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.
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Affiliation(s)
- Samna Haider
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Mohammed Taha Kamal
- Department of General Surgery, Jinnah Medical and Dental College, Karachi, Pakistan
| | - Navaira Shoaib
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mariyam Zahid
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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2
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Asciak R, Bedawi EO, Bhatnagar R, Clive AO, Hassan M, Lloyd H, Reddy R, Roberts H, Rahman NM. British Thoracic Society Clinical Statement on pleural procedures. Thorax 2023; 78:s43-s68. [PMID: 37433579 DOI: 10.1136/thorax-2022-219371] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Affiliation(s)
- Rachelle Asciak
- Respiratory Medicine, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eihab O Bedawi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Maged Hassan
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Heather Lloyd
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Raja Reddy
- Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Helen Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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Garner A, Poynter E, Parsell R, Weatherall A, Morgan M, Lee A. Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults. Eur J Trauma Emerg Surg 2023; 49:571-581. [PMID: 35881149 DOI: 10.1007/s00068-022-02049-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/30/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy. METHODS In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique. RESULTS Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85). CONCLUSIONS There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.
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Affiliation(s)
- Alan Garner
- Nepean Clinical School, Trauma Services, Nepean Hospital, University of Sydney, Derby Street, Kingswood, NSW, 2747, Australia.
| | - Elwyn Poynter
- Research Nurse, CareFlight Australia, Sydney, Australia
| | - Ruth Parsell
- CareFlight Rapid Response Helicopter, Sydney, Australia
| | - Andrew Weatherall
- CareFlight Australia, Division of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Mary Morgan
- Hunter Retrieval Service, John Hunter Hospital, Newcastle, NSW, Australia
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
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Korda T, Baillie-Stanton T, Goldstein LN. An observational simulation-based study of the accuracy of intercostal drain placement and factors influencing placement. Afr J Emerg Med 2022; 12:473-477. [DOI: 10.1016/j.afjem.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 08/22/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022] Open
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Quinn N, Ward G, Ong C, Krieser D, Melvin R, Makhijani A, Grindlay J, Lynch C, Colleran G, Perry V, O'Donnell SM, Law I, Varma D, Fitzgerald J, Mitchell HJ, Teague WJ. Mid‐Arm
Point
in
PAEDiatrics
(MAPPAED): An effective procedural aid for safe pleural decompression in trauma. Emerg Med Australas 2022; 35:412-419. [PMID: 36418011 DOI: 10.1111/1742-6723.14141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 09/27/2022] [Accepted: 10/21/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Nuala Quinn
- Department of Paediatric Emergency Medicine Children's Health Ireland at Temple Street Dublin Ireland
- Emergency Research Group Murdoch Children's Research Institute Melbourne Victoria Australia
- National Office for Trauma Services Dublin Ireland
| | - Grantley Ward
- Melbourne Medical School The University of Melbourne Melbourne Victoria Australia
| | - Cyril Ong
- Department of Medical Imaging The Royal Children's Hospital Melbourne Victoria Australia
| | - David Krieser
- Emergency Research Group Murdoch Children's Research Institute Melbourne Victoria Australia
- Melbourne Medical School The University of Melbourne Melbourne Victoria Australia
- Department of Emergency Medicine, Sunshine Hospital, Western Health Melbourne Victoria Australia
| | - Robert Melvin
- Department of Emergency Medicine, Sandringham Hospital, Alfred Health Melbourne Victoria Australia
| | - Allya Makhijani
- Department of Emergency Medicine, Sunshine Hospital, Western Health Melbourne Victoria Australia
| | - Joanne Grindlay
- Emergency Research Group Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Emergency Medicine The Royal Children's Hospital Melbourne Victoria Australia
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
| | - Catherine Lynch
- Department of Paediatric Emergency Medicine Children's Health Ireland at Temple Street Dublin Ireland
| | - Gabrielle Colleran
- Department of Paediatric Radiology Children's Health Ireland at Temple Street Dublin Ireland
- Department of Paediatrics, Trinity College Dublin and the National Maternity Hospital Dublin Ireland
| | - Victoria Perry
- Trauma Service, The Royal Children's Hospital Melbourne Victoria Australia
| | - Sinead M O'Donnell
- Emergency Research Group Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Emergency Medicine The Royal Children's Hospital Melbourne Victoria Australia
| | - Ian Law
- Department of Emergency Medicine, Sunshine Hospital, Western Health Melbourne Victoria Australia
| | - Dinesh Varma
- Department of Radiology, The Alfred Health Melbourne Victoria Australia
- Department of Surgery Monash University Melbourne Victoria Australia
| | - John Fitzgerald
- Western Health Medical Imaging, Sunshine Hospital, Western Health Melbourne Victoria Australia
| | - Hannah J Mitchell
- Mathematical Sciences Research Centre Queen's University, Belfast UK
| | - Warwick J Teague
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Trauma Service, The Royal Children's Hospital Melbourne Victoria Australia
- Department of Paediatric Surgery The Royal Children's Hospital Melbourne Victoria Australia
- Surgical Research Group Murdoch Children's Research Institute Melbourne Victoria Australia
- School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
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6
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Ghazali DA, Ilha-Schuelter P, Barreyre L, Stephan O, Barbosa SS, Oriot D, Tourinho FSV, Plaisance P. Development and validation of the first performance assessment scale for interdisciplinary chest tube insertion: a prospective multicenter study. Eur J Trauma Emerg Surg 2022; 48:4069-4078. [PMID: 35376968 DOI: 10.1007/s00068-022-01928-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/20/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Daniel Aiham Ghazali
- Emergency Department and EMS, University Hospital of Amiens, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France. .,DREAMS, Department of Research in Emergency Medicine and Simulation, University Hospital and University of Amiens, 80000, Amiens, France. .,IAME "Infection, Antimicrobials, Modelling, Evolution" Research Center, UMR 1137-INSERM, University of Paris, 16 rue Henri Huchard, 75018, Paris, France. .,Simulation Center, University Paris, Paris, France.
| | - Patricia Ilha-Schuelter
- Department of Undergraduate and Graduate Nursing, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Lou Barreyre
- Emergency Department, University Hospital of Bichat, 75018, Paris, France
| | - Olivia Stephan
- Emergency Department, University Hospital of Bichat, 75018, Paris, France
| | - Sarah Soares Barbosa
- Department of Undergraduate and Graduate Nursing, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Denis Oriot
- ABS Lab, Simulation Center of Poitiers University, 86000, Poitiers, France.,Pediatric Emergency Department, University Hospital of Poitiers, 86000, Poitiers, France
| | | | - Patrick Plaisance
- Emergency Department, University Hospital of Lariboisière, 75010, Paris, France.,Ilumens Simulation Center of Paris University, 75018, Paris, France
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7
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Mohrsen S, McMahon N, Corfield A, McKee S. Complications associated with pre-hospital open thoracostomies: a rapid review. Scand J Trauma Resusc Emerg Med 2021; 29:166. [PMID: 34863280 PMCID: PMC8643006 DOI: 10.1186/s13049-021-00976-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/04/2021] [Indexed: 02/26/2023] Open
Abstract
Background Open thoracostomies have become the standard of care in pre-hospital critical care in patients with chest injuries receiving positive pressure ventilation. The procedure has embedded itself as a rapid method to decompress air or fluid in the chest cavity since its original description in 1995, with a complication rate equal to or better than the out-of-hospital insertion of indwelling pleural catheters. A literature review was performed to explore potential negative implications of open thoracostomies and discuss its role in mechanically ventilated patients without clinical features of pneumothorax. Main findings A rapid review of key healthcare databases showed a significant rate of complications associated with pre-hospital open thoracostomies. Of 352 thoracostomies included in the final analysis, 10.6% (n = 38) led to complications of which most were related to operator error or infection (n = 26). Pneumothoraces were missed in 2.2% (n = 8) of all cases. Conclusion There is an appreciable complication rate associated with pre-hospital open thoracostomy. Based on a risk/benefit decision for individual patients, it may be appropriate to withhold intervention in the absence of clinical features, but consideration must be given to the environment where the patient will be monitored during care and transfer. Chest ultrasound can be an effective assessment adjunct to rule in pneumothorax, and may have a role in mitigating the rate of missed cases. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00976-1.
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Affiliation(s)
- Stian Mohrsen
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK. .,Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK9 4LA, Scotland, UK.
| | - Niall McMahon
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK
| | - Alasdair Corfield
- ScotSTAR, Emergency Medical Retrieval Service, 180 Abbotsinch Road, Paisley, PA2 3RY, UK
| | - Sinéad McKee
- Department of Nursing, School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland, UK
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8
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Kikukawa M, Kuriyama A. Massive hemothorax from injury of an anonymous vein after intercostal chest drain placement: A case report. Ann Med Surg (Lond) 2021; 70:102854. [PMID: 34584684 PMCID: PMC8450193 DOI: 10.1016/j.amsu.2021.102854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/26/2022] Open
Abstract
Background Placement of an intercostal chest drain (ICD) is an essential procedure in the management of patients with chest injuries. However, ICD placement can have complications. Here, we report a case of massive hemothorax due to injury of an anonymous vein associated with ICD placement. Case presentation An 84-year-old man with chronic right pleural effusion from pleuroperitoneal communication presented with dyspnea after a fall. An ICD was placed in the right seventh intercostal area on the middle axillary line. He later complained of chest pain and dyspnea again due to right pneumothorax, and massive hemorrhagic pleural effusion was drained from an additionally placed ICD. A contrast-enhanced computed tomography scan showed that bleeding from the parietal pleura traveled along the first ICD and dropped into the intrapleural space. Intraoperatively, there was intramuscular venule bleeding from the right serratus anterior muscle, which was then ligated to stop the bleeding. Discussion An optimal area to place an ICD is termed the "safety triangle", which is determined by the pectoralis major, latissimus dorsi, and the level of the nipples and the base of the axilla. In this case, the ICD was placed in the seventh intercostal area, which is more than two intercostal distances inferior to the 'safety triangle'. Conclusions This case suggested that, even though the vessel was small, a massive, life-threatening hemothorax can occur if an injury is caused by ICD placement. Knowledge of the anatomy necessary for placing an ICD should be reinforced.
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Affiliation(s)
- Motohiro Kikukawa
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan
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9
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Kong V, Cheung C, Rajaretnam N, Sarvepalli R, Weale R, Varghese C, Xu W, Clarke DL. 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. ANZ J Surg 2021; 91:658-661. [PMID: 33719141 DOI: 10.1111/ans.16717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/28/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Cynthia Cheung
- Department of Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | | | | | - Ross Weale
- Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Chris Varghese
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - William Xu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Damian L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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10
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Kamio T, Iizuka Y, Koyama H, Fukaguchi K. Adverse events related to thoracentesis and chest tube insertion: evaluation of the national collection of subject safety incidents in Japan. Eur J Trauma Emerg Surg 2021; 48:981-988. [PMID: 33386863 PMCID: PMC7775838 DOI: 10.1007/s00068-020-01575-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/07/2020] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
- Tadashi Kamio
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Hiroshi Koyama
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Kiyomitsu Fukaguchi
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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11
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Ringel Y, Haberfeld O, Kremer R, Kroll E, Steinberg R, Lehavi A. Intercostal chest drain fixation strength: comparison of techniques and sutures. BMJ Mil Health 2020; 167:248-250. [PMID: 33093024 DOI: 10.1136/bmjmilitary-2020-001555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/06/2020] [Accepted: 09/16/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The accidental removal of an intercostal chest drain (ICD) is common and may result in serious complications. A number of fixation techniques and suture material are in use, and the selection is often based on personal preferences and equipment availability. This study is designed to determine which of the common techniques provides the strongest ICD fixation. METHODS This study compared the mechanical strength of eight different ICD fixation techniques (purse string, 'Roman sandal', 'Jo'burg' (JO) technique, a suture through the tube, one and two passes through a locking plastic tie, tape fixation and a commercial disposable drainage tube holder) and two silk suture sizes using porcine cadavers and a digital push-pull dynamometer to simulate accidental removal of an ICD. A total of 14 different experimental set-ups produced 280 measurements. RESULTS Significant differences in ICD fixation strength were observed. A modified JO technique using a size 1 silk suture was nearly three times stronger than a purse-string fixation using a size 0 silk and 10 times stronger from a commercial, adhesive-based device (180, 70 and 22, respectively). CONCLUSION In situations where the mechanical strength of ICD fixation is important, using a size 1 silk and a modified JO technique may provide the strongest fixation.
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Affiliation(s)
- Yaniv Ringel
- Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - O Haberfeld
- Thoracic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - R Kremer
- Thoracic Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - E Kroll
- Aerospace Engineering, Technion Israel Institute of Technology, Haifa, Haifa, Israel
| | - R Steinberg
- Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - A Lehavi
- Anesthesiology, Rambam Health Care Campus, Haifa, Israel
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12
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O’Keeffe F, Surendran N, Yazbek C, Pandji P, Varma D, Fitzgerald MC, Mitra B. Surface anatomy site for thoracostomy using the axillary hairline. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619875375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Francis O’Keeffe
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Australia
- Emergency Department, Mater Hospital, Dublin, Ireland
| | - Nanda Surendran
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Carl Yazbek
- Department of Radiology, The Alfred Hospital, Melbourne, Australia
| | - Priscilla Pandji
- Monash School of Medicine, Monash University, Melbourne, Australia
| | - Dinesh Varma
- Department of Radiology, The Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Mark C Fitzgerald
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
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13
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Quinn N, Palmer CS, Bernard S, Noonan M, Teague WJ. Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia. Emerg Med Australas 2019; 32:117-126. [PMID: 31531952 DOI: 10.1111/1742-6723.13392] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 07/08/2019] [Accepted: 07/29/2019] [Indexed: 12/18/2022]
Abstract
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.].
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Affiliation(s)
- Nuala Quinn
- Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Temple Street Children's University Hospital, Dublin, Ireland
| | - Cameron S Palmer
- Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Michael Noonan
- Alfred Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Warwick J Teague
- Trauma Service, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatric Surgery, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Surgical Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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14
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Complications Associated With Placement of Chest Tubes: A Trauma System Perspective. J Surg Res 2019; 239:98-102. [DOI: 10.1016/j.jss.2019.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 11/19/2018] [Accepted: 01/04/2019] [Indexed: 11/23/2022]
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15
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Dippenaar E, Wallis L. Pre-hospital intercostal chest drains in South Africa: A modified Delphi study. Afr J Emerg Med 2019; 9:91-95. [PMID: 31193823 PMCID: PMC6543074 DOI: 10.1016/j.afjem.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 10/24/2018] [Accepted: 01/04/2019] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Trauma is one of the most common causes of death in low- and middle-income countries, with thoracic injury accounting for 20-25% of these deaths worldwide. The current management of a life-threatening pre-hospital pneumothorax is with a needle chest decompression, however, definitive care for a pneumothorax and/or haemothorax is still the insertion of an intercostal chest drain. The aim of this study was to seek expert opinion and consensus on the placement of ICDs in the pre-hospital emergency care setting in South Africa. METHODS A three-round modified Delphi study was undertaken with an expert panel drawn from local emergency care experts consisting of physicians and emergency medical service practitioners. Participants supplied opinion statements in round 1 under headings derived from common emerging themes found in the literature. During round 2 participants used a 9-point Likert scale to rate their consensus on each statement and in round 3 they were able to change their position based on the earlier panel distributions. A consensus percentage of 60% was set within a narrow margin of 'strongly agree' or 'strongly disagree'. RESULTS A total of 22 experts took part as panel members. There were 123 opinion statements produced from round 1, of which 21 (17%) reached consensus in round 2. At the end of round 3 another four statements reached consensus, bringing the total up to 25 (20%). CONCLUSION Definitive care of a life-threating pneumothorax and/or haemothorax must be sought emergently. The insertion of an ICD, under select conditions, may be required in the pre-hospital setting in South Africa.
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16
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Teague WJ, Amarakone KV, Quinn N. Rule of 4's: Safe and effective pleural decompression and chest drain insertion in severely injured children. Emerg Med Australas 2019; 31:683-687. [PMID: 31041843 DOI: 10.1111/1742-6723.13299] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Warwick J Teague
- Trauma Service, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Keith V Amarakone
- Trauma Service, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nuala Quinn
- Trauma Service, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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17
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Nyide SP, Brysiewicz P, Bruce J, Clarke DL. A retrospective audit of nursing-related morbidity recorded in a state hospital in KwaZulu-Natal. Curationis 2019; 42:e1-e5. [PMID: 31038327 PMCID: PMC6489142 DOI: 10.4102/curationis.v42i1.1969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/23/2018] [Accepted: 11/01/2018] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Health care professionals are expected to deliver safe and effective health services; however there is increased realisation that adverse events in the health system are a major cause of preventable morbidity and mortality. OBJECTIVES To conduct a retrospective audit of nursing-related morbidities in a state hospital in KwaZulu-Natal, South Africa. METHOD A retrospective audit of nursing-related morbidities documented by the surgical service was carried out using the Hybrid Electronic Medical Registry data for a period of 3 years - 01 November 2013 to 31 October 2016. RESULTS There were a total of 12 444 admissions to surgical service during the study period, with 461 nursing-related morbidities reported. There was an increase in the number of documented nursing-related morbidities noted during November 2015 to October 2016, with 79% of all reported nursing-related morbidities documented during this period. A total of 54% of nursing-related morbidities were associated with males (n = 248) and 46% (n = 213) with females. The most commonly documented nursing-related morbidity was drugs/medication (n = 167, 36%) with the second most common being adjunct management (n = 130, 28%). CONCLUSION The study has identified the most commonly documented nursing-related morbidities in the surgical service of a state hospital. The findings of the study could provide direction for further research and educational initiatives.
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Affiliation(s)
- Spumelelo P Nyide
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban.
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18
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Abstract
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.
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19
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Struck MF, Ewens S, Fakler JKM, Hempel G, Beilicke A, Bernhard M, Stumpp P, Josten C, Stehr SN, Wrigge H, Krämer S. Clinical consequences of chest tube malposition in trauma resuscitation: single-center experience. Eur J Trauma Emerg Surg 2018; 45:687-695. [PMID: 29855668 DOI: 10.1007/s00068-018-0966-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/28/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Evaluation of trauma patients with chest tube malposition using initial emergency computed tomography (CT) and assessment of outcomes and the need for chest tube replacement. METHODS Patients with an injury severity score > 15, admitted directly from the scene, and requiring chest tube insertion prior to initial emergency CT were retrospectively reviewed. Injury severity, outcomes, and the positions of chest tubes were analyzed with respect to the need for replacement after CT. RESULTS One hundred seven chest tubes of 78 patients met the inclusion criteria. Chest tubes were in the pleural space in 58% of cases. Malposition included intrafissural positions (27%), intraparenchymal positions (11%) and extrapleural positions (4%). Injury severity and outcomes were comparable in patients with and without malposition. Replacement due to malfunction was required at similar rates when comparing intrapleural positions with both intrafissural or intraparenchymal positions (11 vs. 23%, p = 0.072). Chest tubes not reaching the target position (e.g., pneumothorax) required replacement more often than targeted tubes (75 vs. 45%, p = 0.027). Out-of-hospital insertions required higher replacement rates than resuscitation room insertions (29 vs. 10%, p = 0.016). Body mass index, chest wall thickness, injury severity, insertion side and intercostal space did not predict the need for replacement. CONCLUSIONS Patients with malposition of emergency chest tubes according to CT were not associated with worse outcomes compared to patients with correctly positioned tubes. Early emergency chest CT in the initial evaluation of severely injured patients allows precise detection of possible malposition of chest tubes that may require immediate intervention.
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Affiliation(s)
- Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Sebastian Ewens
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Johannes K M Fakler
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - André Beilicke
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Patrick Stumpp
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Sebastian N Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Sebastian Krämer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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20
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Mckee J, Mckee I, Bouclin M, Ball CG, McBeth P, Roberts DJ, Atkinson I, Filips D, Kirkpatrick AW. Use of the iTClamp versus standard suturing techniques for securing chest tubes: A randomized controlled cadaver study. Turk J Emerg Med 2018; 18:15-19. [PMID: 29942877 PMCID: PMC6009806 DOI: 10.1016/j.tjem.2018.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/21/2018] [Indexed: 11/16/2022] Open
Abstract
Objectives Tube thoracostomy (TT) is a common yet potentially life-saving trauma procedure. After successful placement however, securing a TT through suturing is a skillset that requires practice, risking that the TT may become dislodged during prehospital transport. The purpose of this study was to examine if the iTClamp was a simpler technique with equivalent effectiveness for securing TTs. Materials and methods In a cadaver model, a 1.5 inch incision was utilized along the upper border of the rib below the 5th intercostal space at the anterior axillary line. TTs (sizes 28Fr, 32Fr, 36Fr and 40Fr) were inserted and secured with both suturing and iTClamp techniques according to the preset randomization. TT were then functionally tested for positive and negative pressure as well as the force required to remove the TT (pull test-up to 5 lbs). Time to secure the TT was also recorded. Results When sutured is placed by a trained surgeon, the sutures and iTClamp were functionally equivalent for holding a positive and negative pressure. Mean pull force for both sutures and iTClamp exceeded the 5 lb threshold; there was no significant difference between the groups. Securing the TT with the iTClamp was significantly faster (p < 0.0001) with the iTClamp having a mean application time of 37.0 ± 22.8 s and using a suture had a man application time of 96.3 ± 29.0 s. Conclusion The iTClamp was effective in securing TTs. The main benefit to the iTClamp is that minimal skill is required to adequately secure a TT to ensure that it does not become dislodged during transport to a trauma center.
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Affiliation(s)
- Jessica Mckee
- Regional Trauma Services, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ian Mckee
- City of Edmonton, Fire Department, Edmonton, AB, Canada
| | - Melanie Bouclin
- North Edmonton Veterinary Emergency, Emergency Department, Edmonton, AB, Canada
| | - Chad G Ball
- Regional Trauma Services, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Paul McBeth
- Regional Trauma Services, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Derek J Roberts
- Department of Surgery, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Ian Atkinson
- Innovative Trauma Care, Clinical Department, Edmonton, AB, Canada
| | - Dennis Filips
- Innovative Trauma Care, Clinical Department, Edmonton, AB, Canada
| | - Andrew W Kirkpatrick
- Regional Trauma Services, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Canadian Forces Health Services, Ottawa, ON, Canada.,Alberta Health Services, Foothills Medical Centre, Calgary, AB, Canada
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21
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Struck MF, Fakler JKM, Bernhard M, Busch T, Stumpp P, Hempel G, Beilicke A, Stehr SN, Josten C, Wrigge H. Mechanical complications and outcomes following invasive emergency procedures in severely injured trauma patients. Sci Rep 2018; 8:3976. [PMID: 29507415 PMCID: PMC5838247 DOI: 10.1038/s41598-018-22457-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/23/2018] [Indexed: 11/16/2022] Open
Abstract
This study aimes to determine the complication rates, possible risk factors and outcomes of emergency procedures performed during resuscitation of severely injured patients. The medical records of patients with an injury severity score (ISS) >15 admitted to the University Hospital Leipzig from 2010 to 2015 were reviewed. Within the first 24 hours of treatment, 526 patients had an overall mechanical complication rate of 26.2%. Multivariate analysis revealed out-of-hospital airway management (OR 3.140; 95% CI 1.963–5.023; p < 0.001) and ISS (per ISS point: OR 1.024; 95% CI 1.003–1.045; p = 0.027) as independent predictors of any mechanical complications. Airway management complications (13.2%) and central venous catheter complications (11.4%) were associated with ISS >32.5 (p < 0.001) and ISS >33.5 (p = 0.005), respectively. Chest tube complications (15.8%) were associated with out-of-hospital insertion (p = 0.002) and out-of-hospital tracheal intubation (p = 0.033). Arterial line complications (9.4%) were associated with admission serum lactate >4.95 mmol/L (p = 0.001) and base excess <−4.05 mmol/L (p = 0.008). In multivariate analysis, complications were associated with an increased length of stay in the intensive care unit (p = 0.019) but not with 24 hour mortality (p = 0.930). Increasing injury severity may contribute to higher complexity of the individual emergency treatment and is thus associated with higher mechanical complication rates providing potential for further harm.
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Affiliation(s)
- Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Johannes K M Fakler
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Thilo Busch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Patrick Stumpp
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - André Beilicke
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Sebastian N Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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22
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Fang Y, Xiao H, Sha W, Hu H, You X. Comparison of closed-chest drainage with rib resection closed drainage for treatment of chronic tuberculous empyema. J Thorac Dis 2018; 10:347-354. [PMID: 29600066 DOI: 10.21037/jtd.2017.11.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to compare the efficacy of closed-chest drainage with rib resection closed drainage of chronic tuberculous empyema. Methods This retrospective study reviewed 86 patients with tuberculous empyema in Shanghai Pulmonary Hospital from August 2010 to November 2015. Among these included patients, 22 patients received closed-chest drainage, and 64 patients received rib resection closed drainage. Results The results showed that after intercostal chest closed drain treatment, 2 (9.09%) patients were recovery, 13 (59.09%) patients had significantly curative effect, 6 (27.27%) patients had partly curative effect, and 1 (4.55%) patient had negative effect. After treatment of rib resection closed drainage, 9 (14.06%) patients were successfully recovery, 31 (48.44%) patients had significantly curative effect, 19 (29.69%) patients had partly curative effect, and 5 (7.81%) patients had negative effect. There was no significant difference in the curative effect (P>0.05), while the average catheterization time of rib resection closed drainage (130.05±13.12 days) was significant longer than that (126.14±36.84 days) in course of intercostal chest closed drain (P<0.05). Conclusions This study had demonstrated that closed-chest drainage was an effective procedure for treating empyema in young patients. It was less invasive than rib resection closed drainage and was associated with less severe pain. We advocated closed-chest drainage for the majority of young patients with empyema, except for those with other diseases.
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Affiliation(s)
- Yong Fang
- Clinic and Research Center of Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Heping Xiao
- Clinic and Research Center of Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Wei Sha
- Clinic and Research Center of Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Haili Hu
- Clinic and Research Center of Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Xiaofang You
- Clinic and Research Center of Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
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23
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Ablett DJ, Navaratne L, Chua D, Streets CG, Tai NRM. The modified 'Jo'burg' technique for securing intercostal chest drains. J ROY ARMY MED CORPS 2017; 163:319-323. [PMID: 28652316 DOI: 10.1136/jramc-2016-000744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/15/2017] [Accepted: 03/18/2017] [Indexed: 11/03/2022]
Abstract
Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as an emergency procedure during the initial resuscitation period and often within a stressful environment. Approximately one-fifth of all ICD insertions are associated with complications. In a retrospective review of over 1000 ICD insertions, 7% of the complications observed were due to inadequate fixation, resulting in dislodgement. The risk of dislodgement is greatest during transit or transfer of a casualty. In a military setting, this may involve movement of a casualty in a non-permissive environment and includes transfer on and off rotary wing, fixed wing, road vehicle and maritime transport platforms as well as between stretchers and hospital beds. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines, the method of securing ICDs has not been standardised across the Defence Medical Services (DMS). The aim of this paper is to first propose a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand. Second, we present the results from a pilot validation study of this technique when introduced to candidates on a trauma surgical skills course. We describe and demonstrate a robust, easily teachable and reproducible technique for securing ICDs. We would advocate the use of this technique among both surgically and non-surgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. This could be easily implemented by introducing this technique into the various military trauma courses, for example the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses.
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Affiliation(s)
- Daniel J Ablett
- Royal London Hospital, London, UK.,Defence Medical Services, DMS Whittington, Lichfield, UK
| | - L Navaratne
- Royal London Hospital, London, UK.,Defence Medical Services, DMS Whittington, Lichfield, UK
| | - D Chua
- Royal College of Surgeons of Ireland, Dublin, Ireland
| | - C G Streets
- Defence Medical Services, DMS Whittington, Lichfield, UK.,Bristol Royal Infirmary, Bristol, UK
| | - N R M Tai
- Royal London Hospital, London, UK.,Defence Medical Services, DMS Whittington, Lichfield, UK
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24
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Management of Traumatic Hemothorax, Retained Hemothorax, and Other Thoracic Collections. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0101-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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25
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Bing F, Fitzgerald M, Olaussen A, Finnegan P, O'Reilly G, Gocentas R, Stergiou H, Korin A, Marasco S, McGiffin D. Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP). JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2017. [DOI: 10.5339/jemtac.2017.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Fei Bing
- 1Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
- 2National Trauma Research Institute, Melbourne, Victoria, Australia
- 5Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- 1Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
- 2National Trauma Research Institute, Melbourne, Victoria, Australia
- 5Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- 5Central Clinical School, Monash University, Melbourne, Victoria, Australia
- 1Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
- 6Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
- 3Emergency & Trauma Centre, The Alfred, Hospital, Melbourne, Victoria, Australia
- 2National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Pete Finnegan
- 1Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
- 2National Trauma Research Institute, Melbourne, Victoria, Australia
- 3Emergency & Trauma Centre, The Alfred, Hospital, Melbourne, Victoria, Australia
| | - Gerard O'Reilly
- 2National Trauma Research Institute, Melbourne, Victoria, Australia
- 3Emergency & Trauma Centre, The Alfred, Hospital, Melbourne, Victoria, Australia
- 5Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Rob Gocentas
- 2National Trauma Research Institute, Melbourne, Victoria, Australia
- 3Emergency & Trauma Centre, The Alfred, Hospital, Melbourne, Victoria, Australia
| | - Helen Stergiou
- 2National Trauma Research Institute, Melbourne, Victoria, Australia
- 3Emergency & Trauma Centre, The Alfred, Hospital, Melbourne, Victoria, Australia
| | - Anna Korin
- 3Emergency & Trauma Centre, The Alfred, Hospital, Melbourne, Victoria, Australia
| | - Silvana Marasco
- 4Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- 5Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David McGiffin
- 4Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- 5Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Hernandez MC, Vogelsang D, Anderson JR, Thiels CA, Beilman G, Zielinski MD, Aho JM. Visually guided tube thoracostomy insertion comparison to standard of care in a large animal model. Injury 2017; 48:849-853. [PMID: 28238448 PMCID: PMC5427288 DOI: 10.1016/j.injury.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/03/2017] [Accepted: 02/17/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Matthew C. Hernandez
- Department of Surgery, Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | | | | | | | - Gregory Beilman
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Martin D. Zielinski
- Department of Surgery, Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | - Johnathon M. Aho
- Department of Surgery, Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
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Klein WM, Van der Putten ME, Kusters B, Verhoeven BH. Fatal Complications after Pediatric Surgical Interventions: Lessons Learned. European J Pediatr Surg Rep 2017; 5:e12-e16. [PMID: 28344917 PMCID: PMC5363334 DOI: 10.1055/s-0037-1599795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Placement of catheters, drains, shunts, and tubes in children can lead to serious or even fatal complications at the moment of placement, such as hemorrhage at insertion, or in the longterm, such as infections and migration into adjacent organs. The clinician should always be aware of these potential complications, especially if the child is unwell. For postmortem diagnostic evaluation, either with a computed tomography scan or an invasive autopsy, all tubes, drains, shunts, and/or catheters should be left in situ. We present three cases with fatal complications after the placement of a chest drain, ventriculoperitoneal shunt, and gastrostomy tube.
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Affiliation(s)
- Willemijn M Klein
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Benno Kusters
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bas H Verhoeven
- Department of Pediatric Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
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.
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Affiliation(s)
- Tamas F Molnar
- Department of Operational Medicine, Faculty of Medicine, University of Pécs, H7622 Pécs, Szigeti út 12, Hungary; Thoracic Surgery Unit, Department of Surgery, Aladar Petz Teaching Hospital, H9032 Győr, Vasvari Pál utca 2-4, Hungary.
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Kong VY, Oosthuizen GV, Sartorius B, Keene CM, Clarke DL. Correlation between ATLS training and junior doctors' anatomical knowledge of intercostal chest drain insertion. JOURNAL OF SURGICAL EDUCATION 2015; 72:600-605. [PMID: 25814320 DOI: 10.1016/j.jsurg.2015.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/17/2015] [Accepted: 01/29/2015] [Indexed: 06/04/2023]
Abstract
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.
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Affiliation(s)
- Victor Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Pietermaritzburg, South Africa.
| | - George V Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Benn Sartorius
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Claire M Keene
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Damian L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Pietermaritzburg, South Africa
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