Accuracy of Needle Thoracostomy Site Selection among US Army Medics.

BACKGROUND: Tension pneumothorax is a prominent cause of potentially survivable death on the battlefield. Field management for suspected tension pneumothorax is immediate needle thoracostomy (NT). Recent data noted higher NT success rates and ease of insertion at the fifth intercostal space, anterior axillary line (5th ICS AAL), leading to an amendment of the Committee on Tactical Combat Casualty Care recommendations on managing suspected tension pneumothorax to include the 5th ICS AAL as a viable alternative site for NT placement. The objective of this study was to assess the overall accuracy, speed, and ease of NT site selection and compare these outcomes between the second intercostal space, midclavicular line (2nd ICS MCL) and 5th ICS AAL among a cohort of Army medics. METHODS: We designed a prospective, observational, comparative study and recruited a convenience sample of US Army medics from a single military installation to localize and mark the anatomic location where they would perform an NT at the 2nd ICS MCL and 5th ICS AAL on 6 live human models. The marked site was compared for accuracy to an optimal site predetermined by investigators. We assessed the primary outcome of accuracy via concordance with the predetermined NT site location at the 2nd ICS MCL and 5th ICS MCL. Secondarily, we compared time to final site marking and the influence of model body mass index (BMI) and gender on accuracy of selection between sites. RESULTS: A total of 15 participants performed 360 NT site selections. We found a significant difference between participants' ability to accurately target the 2nd ICS MCL compared to the 5th ICS AAL (42.2% versus 10% respectively, p is less than 0.001). The overall accuracy rate among all NT site selections was 26.1%. We also found a significant difference in time-to-site identification between the 2nd ICS MCL and 5th ICS AAL in favor of the 2nd ICS MCL (median [IQR] 9 [7.8] seconds versus 12 [12] seconds, p is less than 0.001). CONCLUSIONS: US Army medics may be more accurate and faster at identifying the 2nd ICS MCL when compared to the 5th ICS AAL. However, overall site selection accuracy is unacceptably low, highlighting an opportunity to enhance training for this procedure.

Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Traumatic hemothorax poses diagnostic and therapeutic challenges both acutely and chronically. A working group of the Eastern Association for the Surgery of Trauma convened to formulate a practice management guideline for traumatic hemothorax. METHODS: We formulated four questions: whether tube thoracostomy vs observation be performed, should pigtail catheter versus thoracostomy tube be placed to drain hemothorax, should thrombolytic therapy be attempted versus immediate thoracoscopic assisted drainage (VATS) in retained hemothorax (rHTX), and should early VATS (≤4 days) versus late VATS (>4 days) be performed? A systematic review was undertaken from articles identified in multiple databases. RESULTS: A total of 6391 articles were identified, 14 were selected for guideline construction. Most articles were retrospective with very low-quality evidence. We performed meta-analysis for some of the outcomes for three of the questions. CONCLUSIONS: For traumatic hemothorax we conditionally recommend pigtail catheters, in hemodynamically stable patients. In patients with rHTX, we conditionally recommend VATS rather than attempting thrombolytic therapy and recommend that it should be performed early (≤4 days).

Chest Tube Management Practices by Trauma Surgeons.

BACKGROUND: Chest tube (CT) placement is among the most common procedures performed by trauma surgeons; evidence guiding CT management is limited and tends toward thoracic surgery patients. The study goal was to identify current CT management practices among trauma providers. MATERIALS AND METHODS: We designed a Web-based multiple-choice survey to assess CT management practices of trauma providers who were active, senior, or provisional members (n = 1890) of the Eastern Association for the Surgery of Trauma and distributed via e-mail. Descriptive statistics were used. RESULTS: The response rate was 39% (n = 734). Ninety-one percent of respondents were attending surgeons, the remainder fellows or residents. Regarding experience, 36% of respondents had five or fewer years of practice, 54% 10 y or fewer, and 79% 20 y or fewer. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with experience of <5 y were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CTs for hemothorax and unstable patients with PTX, and larger tubes for unstable patients with hemothorax. Most respondents (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice. CONCLUSIONS: Trauma CT management is variable and nonstandardized, depending mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.

Transoceanic Telementoring of Tube Thoracostomy Insertion: A Randomized Controlled Trial of Telementored Versus Unmentored Insertion of Tube Thoracostomy by Military Medical Technicians.

Background:Tension pneumothorax is a frequent cause of potentially preventable death. Tube thoracostomy (TT) can obviate death but is invasive and fraught with complications even in experienced hands. We assessed the utility of a remote international virtual network (RIVN) of specialized mentors to remotely guide military medical technicians (medics) using wireless informatics.Methods:Medics were randomized to insert TT in training mannequins (TraumaMan; Abacus ALS, Meadowbrook, Australia) supervised by RIVN or not. The RIVN consisted of trauma surgeons in Canada and Australia and a senior medic in Ohio. Medics wore a helmet-mounted wireless camera with laser pointer to confirm anatomy and two-way voice communication using commercial software (Skype®). Performance was measured through objective task completion (pass/fail) regarding safety during the procedure, proper location, and secure anchoring of the tube, in addition to remote mentor opinion and subjective debrief.Results:Fourteen medics attempted TT, seven mentored and seven not. The RIVN was functional and surgeons on either side of the globe had real-time communication with the mentees. TT placement was considered safe, successful, and secure in 100% of mentored (n = 7) procedures, although two (29%) received corrective remote guidance. All (100%) of the unmentored attempted and adequately secured the TT and were safe. However, only 71% (n = 5) completed the task successfully (p = 0.46). Participating medics subjectively felt remote telementoring (RTM) increased self-confidence (strong agreement mean 5/5 ± 0); confidence to perform field TT (agreement (4/5 ± 1); and decreased anxiety (strong agreement 5/5 ± 1). Subjectively, the remote mentors felt in 100% of the mentored procedures that "yes" they were able to assist the medics (1.86 ± 0.38), and in 71% (n = 5) felt "yes" they made TT safer (2.29 ± 0.49).Conclusions:RTM descriptively increased the success of TT placement and allowed for real-time troubleshooting from thousands of kilometers with a redundant capability. RTM was subjectively associated with high levels of satisfaction and self-reported self-confidence. Continued controlled and critical evaluation and refinement of telemedical techniques should continue. Trial Registration: ID ISRCTN/77929274.

Outcomes of an initiative to improve inpatient safety of small bore thoracostomy tube insertion.

BACKGROUND: Intercostal chest catheter (ICC) insertion is a common hospital procedure with attendant risks including life-threatening complications such as pneumothorax and visceral damage. AIM: To investigate the effect of a quality improvement (QI) initiative on complications associated with inpatient thoracostomy tube insertion. METHODS: Following an audit of ICC complications in inpatients over a 2-year period we implemented a comprehensive QI programme. This involved formal training in and mandatory use of thoracic ultrasound, standardisation of the procedure and documentation, a dedicated procedure room with nurses trained in assisting ICC insertion and senior supervision for medical staff. An audit over 2 years post-implementation of the QI protocol was compared with pre-implementation results. RESULTS: A total of 103 cases were reviewed pre-implementation and 105 cases were reviewed post-implementation of the QI programme. All procedures following the QI initiative were image guided compared to 23.3% of cases pre-implementation. The rate of developing a pneumothorax requiring intervention post-implementation was less than pre-implementation (1.9% vs 5.8% (P = 0.023). Post-implementation, there were no instances of dry taps, viscera perforation, clinically significant bleeding or wrong side ICC insertion and documentation improved. CONCLUSION: QI initiative applied to thoracostomy tube insertion in hospital inpatients can reduce complications and improve procedure documentation.

Persistent air leak - review.

A persistent air leak (PAL) can be caused by either an alveolar-pleural fistula (APF) or bronchopleural fistula (BPF). Complications from PAL lead to an increase in morbidity and mortality, prolonged hospital stay, and higher resource utilization. Pulmonary physicians and thoracic surgeons are often tasked with the difficult and often times frustrating diagnosis and management of PALs. While most patients will improve with chest tube thoracostomy, many will fail requiring alternative bronchoscopic or surgical strategies. Herein, we review the bronchoscopic and surgical diagnostic and treatment options for PAL as it pertains to the field of interventional pulmonology and thoracic surgery.

BET1: Pre-hospital finger thoracostomy in patients with traumatic cardiac arrest.

A short cut review was carried out to see if 'finger' thoracostomy was a safe and effective procedure to use in the pre-hospital setting in patients with traumatic cardiac arrest. Three relevant papers were found describing the use of this technique in the pre-hospital setting. The author, date and country of publication, patient group studied, study type, relevant outcomes, results study weaknesses of these papers are tabulated. Finger thoracostomy appears to be an acceptable and effective technique for trained physicians in the pre-hospital setting.

BET 2: Pre-hospital finger thoracostomy in patients with chest trauma.

A short cut review was carried out to see if 'finger' thoracostomy is a safe and effective method of treating a tension pneumothorax in a pre-hospital setting. Five relevant papers were found looking at this technique in the pre-hospital setting. The author, date and country of publication, patient group studied, study type, relevant outcomes, results study weaknesses of these papers are tabulated. This technique appears to be safe and effective when performed by trained physicians in a pre-hospital setting.

A new instrument to assess physician skill at chest tube insertion: the TUBE-iCOMPT.

Currently no tool exists to assess proceduralist skill at chest tube insertion. As inadequate doctor procedural competence has repeatedly been associated with adverse events, there is a need for a tool to assess procedural competence. This study aims to develop and examine the validity of a tool to assess competency at insertion of a chest tube, using either the Seldinger technique or blunt dissection. A 5-domain 100-point assessment tool was developed inline with British Thoracic Society guidelines and international consensus­the Chest Tube Insertion Competency Test (TUBE-iCOMPT). The instrument was used to assess chest tube insertion in mannequins and live patients. 29 participants (9 novices, 14 intermediate and 6 advanced) were tested by 2 blinded expert examiners on 2 occasions. The tool's validity was examined by demonstrating: (1) stratification of participants according to expected level of expertise (analysis of variance), and (2) test-retest and intertester reliability (intraclass correlation coefficient). The intraclass correlation coefficient of repeated scores for the Seldinger technique and blunt dissection, were 0.92 and 0.91, respectively, for test-retest results, and 0.98 and 0.95, respectively, for intertester results. Clear stratification of scores according to participant experience was seen (p<0.0001). There was no significant difference between scores obtained using mannequins or live patients. This study has validated the TUBE-iCOMPT, which could now be incorporated into chest tube insertion training programmes, providing a way to document acquisition of skill, guide individualised teaching, and assist with the assessment of the adequacy of clinician training.

Identifying the site for intercostal catheter insertion in the emergency department: is clinical examination reliable?

OBJECTIVE: To determine whether ED doctors, comprising both consultants and registrars, can accurately identify the 4th or 5th intercostal space (ICS), commonly used for intercostal catheter insertion. METHODS: An observational study was designed using a sample of ED doctors applying their clinical skills to a convenience sample of patients reflecting a heterogeneous mix of ED patients. Patients already receiving a CXR in our ED were examined by a registrar or consultant who placed a radiopaque marker on the patients' chest wall over the site they determined to be the 4th or 5th ICS. Consultant radiologists reported the marker's position from postero-anterior projection CXRs, and results were analysed comparing consultants with registrars, right to left hemithoraces and male to female patients. RESULTS: ED doctors participating in the present study placed the marker over the 4th or 5th ICS 36.2% of the time, with no significant difference between consultant and registrar groups, nor right or left hemithoraces. Accuracy was improved in female patients compared with male patients. CONCLUSION: Emergency registrars and consultants sampled from a regional ED appeared unable to reliably identify the 4th or 5th ICS, as evidenced by marker position, in a heterogeneous patient population.

Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: Antibiotic use in injured patients requiring tube thoracostomy (TT) to reduce the incidence of empyema and pneumonia remains a controversial practice. In 1998, the Eastern Association for the Surgery of Trauma (EAST) developed and published practice management guidelines for the use of presumptive antibiotics in TT for patients who sustained a traumatic hemopneumothorax. The Practice Management Guidelines Committee of EAST has updated the 1998 guidelines to reflect current literature and practice. METHODS: A systematic literature review was performed to include prospective and retrospective studies from 1997 to 2011, excluding those studies published in the previous guideline. Case reports, letters to the editor, and review articles were excluded. Ten acute care surgeons and one statistician/epidemiologist reviewed the articles under consideration, and the EAST primer was used to grade the evidence. RESULTS: Of the 98 articles identified, seven were selected as meeting criteria for review. Two questions regarding presumptive antibiotic use in TT for traumatic hemopneumothorax were addressed: (1) Do presumptive antibiotics reduce the incidence of empyema or pneumonia? And if true, (2) What is the optimal duration of antibiotic prophylaxis? CONCLUSION: Routine presumptive antibiotic use to reduce the incidence of empyema and pneumonia in TT for traumatic hemopneumothorax is controversial; however, there is insufficient published evidence to support any recommendation either for or against this practice.

Intercostal catheter insertion: are we really doing well?

INTRODUCTION: Intercostal catheters (ICC) are the standard management of chest trauma, but are associated with complications in up to 30%. The aim of this study was to evaluate errors in technique during ICC insertion to characterize the potential benefit of improved training programmes. METHODS: Prospective audit of all ICC in trauma patients at a level 1 trauma centre for over 12 months. Exclusions were pigtail catheters and ICC inserted during thoracic surgery. Errors were identified from patient examination and chest imaging; they were defined as insertional, positional, incorrect size (<28 French) and lack of antibiotic prophylaxis. Ongoing complications unrelated to an error in technique, for example blocked tube, were not analysed. RESULTS: Fifty-seven patients received a total of 94 ICC during the study period. Patients were predominantly male (77%), mean age of 40 ± 20 years, mean injury severity score 27 ± 13, mean abbreviated injury scale chest 3.8 ± 0.72. 86% were blunt trauma and 14% penetrating chest injuries. Thirty-six errors in technique occurred in 33 ICC insertions (38%). The most common errors were absence of prophylactic antibiotics (13%), ICC too far out (9%), kinked (6%) and wrong-sized ICC (5%). Emergency had a significantly greater frequency of errors than other specialties (67%, relative risk 2.11, P= 0.002). The majority of ICC were inserted by registrars, and registrars made a greater number of errors than fellows or consultants (relative risk 2.00, P= 0.02). DISCUSSION: This study identified a large number of preventable errors for ICC insertion in trauma patients. Standardized institutional credentialing systems may be required to ensure adequate proficiency of trainees performing this procedure.

A simple device to teach tube thoracostomy.

BACKGROUND: Chest tube insertion is an important component of medical and surgical education. This article reports a cost-effective and easily reproducible method for hands-on education of tube thoracostomy placement. METHODS: A wood base is constructed, and a large rack of ribs are secured to simulate the thorax. Partially inflated examination gloves and bagels are used to simulate the lung and diaphragm, respectively. RESULTS: A life-like, cost-efficient thoracostomy model is created allowing for proficiency training in chest tube insertion. According to Advanced Trauma Life Support criteria, 123 military personnel were satisfactory, 4 remedial, and 7 instructor potential using the described model. CONCLUSIONS: We have developed a simple, inexpensive training device for insertion of chest tubes and tested it on 134 military personnel.

The anterior to midaxillary line between the 4th or 5th intercostal space (Buelau position) is safe for the use of thoracostomy tubes in preterm and term infants.

OBJECTIVES: Thoracostomy tubes are widely used in neonatology. Complications occurred significantly more frequently in infants, especially neonates, than in adults. Principally, the access is the modified Buelau position which takes place in the anterior axillary line at the 4th or 5th intercostal space above the margin of the ribs. AIM: This study seeks to determine the characteristics and topographic conditions of the anatomical structures at the ventral and lateral thoracic wall in the preterm and term neonate. BACKGROUND: Fifteen formalin-fixed stillborns were prepared (nine male, six female, 28-43 weeks gestational age). METHODS/MATERIALS: The anatomical preparation involved the complete thoracic wall region. RESULTS: In all preparations, a venous vessel was detected at the lateral wall and was identified as v. thoracoepigastrica without accompanying artery. Arteria (a.) and vena (v.) thoracica interna were regularly found close to the sternal plate on both sides between rib and fascia. With increasing gestational ages the course of the v. thoracoepigastrica varied significantly between the left and right thoracic wall. It was demonstrated that the v. thoracoepigastrica regularly arose within the abdominal or thoracic subcutaneous fat and drained into the v. subclavia. The variance between its course was almost 5-12 mm to the lateral or medial side. At both thoracic sides, no other organs or organ structures except lung parenchyma could be detected when using the Buelau position. CONCLUSIONS: The anterior to midaxillary line between the 4th or 5th intercostal space (Buelau position) is safe for the use of thoracostomy tubes in preterm and term infants.

Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography.

OBJECTIVE: Tension pneumothorax can lead to cardiovascular collapse and death. In the prehospital setting, needle thoracostomy for emergent decompression may be lifesaving. Taught throughout the United States to emergency medical technicians (EMTs) and physicians, the true efficacy of this procedure is unknown. Some question the utility of this procedure in the prehospital setting, doubting that the needle actually enters the pleural space. This study was designed to determine if needle decompression of a suspected tension pneumothorax would access the pleural cavity as predicted by chest computed tomography (CT). METHODS: We retrospectively reviewed consecutive adult trauma patients admitted to a level I trauma center between January and March 2005. We measured chest wall depth at the second intercostal space, midclavicular line on CT scans. Data on chest wall thickness were compared with the standard 4.4-cm angiocatheter used for needle decompression. RESULTS: Data from 110 patients were analyzed. The mean age of the patients was 43.5 years. The mean chest wall depth on the right was 4.5 cm (+/- 1.5 cm) and on the left was 4.1 cm (+/- 1.4 cm). Fifty-five of 110 patients had at least one side of the chest wall measuring greater than 4.4 cm. CONCLUSIONS: The standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7-59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration.

Pleural decompression and drainage during trauma reception and resuscitation.

This review examines pleural decompression and drainage during initial hospital adult trauma reception and resuscitation, when it is indicated for haemodynamically unstable patients with signs of pneumothorax or haemothorax. The relevant historical background, techniques, complications and current controversies are highlighted. Key findings of this review are that: 1. Needle thoracocentesis is an unreliable means of decompressing the chest of an unstable patient and should only be used as a technique of last resort. 2. Blunt dissection and digital decompression through the pleura is the essential first step for pleural decompression, as decompression of the pleural space is a primary goal during reception of the haemodynamically unstable patient with a haemothorax or pneumothorax. Drainage and insertion of a chest tube is a secondary priority. 3. Techniques to prevent tube thoracostomy (TT) complications include aseptic technique, avoidance of trocars, digital exploration of the insertion site and guidance of the tube posteriorly and superiorly during insertion. 4. Whenever possible, blunt thoracic trauma patients should undergo definitive CT imaging after TT to check for appropriate tube position.