Results of a clinical practice algorithm for the management of thoracostomy tubes placed for traumatic mechanism

Abstract

IntroductionThe management and removal of thoracostomy tubes for trauma-related hemothorax and pneumothorax is controversial. General recommendations exist; however, institutional data related to an algorithmic approach has not been well described. The difficulty in establishing an algorithm centers about individualized patients’ needs for subsequent management after thoracostomy tube placement. In our institution, we use the same protocol for all trauma patients who receive a thoracostomy tube with minimal complications.PurposeTo present the clinical outcomes of patients who required a tube thoracostomy for traumatic injury and were managed by an institutional protocol.MethodsA retrospective chart review of 313 trauma patients at a single level I trauma institution from January 2008 through June 2012 was conducted. Inclusion criteria were patient age ≥ 18 years, involvement in a trauma, and requirement of a thoracostomy tube. The patients’ charts were reviewed for demographic data, injury severity score (ISS), length of stay (LOS), and chest-tube specific data. Thoracostomy tube complications were defined as persistent air leak, persistent pneumothorax, recurrent pneumothorax, and clotting of thoracostomy tube. The patients were managed per our institutional algorithm. Descriptive statistics were performed.ResultsMost of the patients who required a thoracostomy tube had blunt-related traumas (271/313; 86.6%), while 42 patients (13.4%) sustained penetrating injuries. There were 215 (68.7%) male patients. The average age at time of injury was 45.7 ± 21.1 years and the mean ISS was 24.9 ± 15.9 (mean ± SD). Elevated alcohol levels were found in 65 of the 247 patients who were tested upon admission (26.3%). Overall, 15 patients (4.8%) developed a thoracostomy tube related complication: persistent air leak in six patients, persistent pneumothorax in six patients, recurrent pneumothorax in two patients, and clotted thoracostomy tube in one patient. The average LOS was 10.4 ± 8.4 days, and the mean length of thoracostomy tube placement was 5.9 ± 4.3 days.ConclusionsOur algorithmic thoracostomy tube management protocol resulted in a complication rate of 4.8%. By managing thoracostomy tubes in a systematic manner, our patients have improved outcomes following placement and removal compared to other studies.

The analysis of 89 patients that performed tube thoracostomy by general surgeons

“…In several studies, the rate of complications was reported to vary between 4.8% and 30% (16)(17)(18)(19)(20), consistent with our study findings (2.2%). Duration of the removal of the tube, length of hospital stay, and development of complications related to the thoracic tube have been associated with severity of injury.…”

“…Duration of the removal of the tube, length of hospital stay, and development of complications related to the thoracic tube have been associated with severity of injury. The specialty of the health professional, such as surgery or emergency medicine, inserting the thoracic tube and the team transporting the patients have been also implicated in the development of complications (16).…”

Large thoracic defect due to shotgun violation – surgical emergency management

“…Next to intubation and intravenous volume supply the tamponade of the bleeding wound will initially operate predominantly to prevent bleeding to death. Afterwards, a wide lumen thoracic drainage (at least 28 Ch) has to be placed via “minithoracotomy” to prevent a tension pneumothorax caused by the tamponade (insertion of trocars is contraindicated) [ 31 ], [ 32 ], [ 33 ]. Nevertheless a tension pneumothorax can develop for example because of malposition of the drainage or obstruction through blood clots [ 31 ], [ 32 ], [ 33 ], [ 34 ], [ 35 ], [ 36 ], [ 37 ].…”

“…Afterwards, a wide lumen thoracic drainage (at least 28 Ch) has to be placed via “minithoracotomy” to prevent a tension pneumothorax caused by the tamponade (insertion of trocars is contraindicated) [ 31 ], [ 32 ], [ 33 ]. Nevertheless a tension pneumothorax can develop for example because of malposition of the drainage or obstruction through blood clots [ 31 ], [ 32 ], [ 33 ], [ 34 ], [ 35 ], [ 36 ], [ 37 ]. An increase in blood pressure and a decrease in oxygenation as well as a volume-resistant shock [ 34 ] are warning signs concerning this matter and should effect the placement of a second wide lumen drainage [ 14 ], [ 16 ], [ 33 ], [ 34 ].…”

Early and Persistent Hemothorax and Pneumothorax

“…Overall, when compared to a penetrating mechanism of injury, patients with a blunt mechanism of injury tend to have longer intensive care unit stays, more ventilator days, and more tube thoracostomy days [28]. Some suggest that the utilization of a clinical practice algorithm, especially in patients with an elevated chest Abbreviated Injury Score (AIS), can decrease the morbidity associated with tube thoracostomy management and eventual removal [29,30]. Though our current practice is to obtain a chest radiograph on removal of thoracostomy tubes, others have proposed the utility of such a film is low in the absence of clinical signs exhibited by the patient [31].…”