Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm.

ABSTRACT: This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. LEVEL OF EVIDENCE: Consensus algorithm from the Western Trauma Association, Level V.

Not so FAST-Chest ultrasound underdiagnoses traumatic pneumothorax.

BACKGROUND: Ultrasonography for trauma is a widely used tool in the initial evaluation of trauma patients with complete ultrasonography of trauma (CUST) demonstrating equivalence to computed tomography (CT) for detecting clinically significant abdominal hemorrhage. Initial reports demonstrated high sensitivity of CUST for the bedside diagnosis of pneumothorax. We hypothesized that the sensitivity of CUST would be greater than initial supine chest radiograph (CXR) for detecting pneumothorax. METHODS: A retrospective analysis of patients diagnosed with pneumothorax from 2018 through 2020 at a Level I trauma center was performed. Patients included had routine supine CXR and CUST performed prior to intervention as well as confirmatory CT imaging. All CUST were performed during the initial evaluation in the trauma bay by a registered sonographer. All imaging was evaluated by an attending radiologist. Subgroup analysis was performed after excluding occult pneumothorax. Immediate tube thoracostomy was defined as tube placement with confirmatory CXR within 8 hours of admission. RESULTS: There were 568 patients screened with a diagnosis of pneumothorax, identifying 362 patients with a confirmed pneumothorax in addition to CXR, CUST, and confirmatory CT imaging. The population was 83% male, had a mean age of 45 years, with 85% presenting due to blunt trauma. Sensitivity of CXR for detecting pneumothorax was 43%, while the sensitivity of CUST was 35%. After removal of occult pneumothorax (n = 171), CXR was 78% sensitive, while CUST was 65% sensitive (p < 0.01). In this subgroup, CUST had a false-negative rate of 36% (n = 62). Of those patients with a false-negative CUST, 50% (n = 31) underwent tube thoracostomy, with 85% requiring immediate placement. CONCLUSION: Complete ultrasonography of trauma performed on initial trauma evaluation had lower sensitivity than CXR for identification of pneumothorax including clinically significant pneumothorax requiring tube thoracostomy. Using CUST as the primary imaging modality in the initial evaluation of chest trauma should be considered with caution. LEVEL OF EVIDENCE: Diagnostic Test study, Level IV.

Beyond the tube: Can we reduce chest tube complications in trauma patients?

BACKGROUND: We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT). METHODS: Retrospective review of all trauma patients undergoing TT from 6/30/2016-6/30/2019. Multivariable logistic regression identified independent predictors of complications. RESULTS: Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m2 were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%-53.5%), and early complication increased the likelihood of late complication (4.3%-13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication. CONCLUSION: TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m2. We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes.

Development and evolution of a robotic surgical technique for the treatment of thoracic outlet syndrome.

OBJECTIVE: We describe the development and evolution of a surgical technique that uses the robotic da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif) for the transaxillary approach to repair the disabling thoracic outlet syndrome (TOS). We report our patient outcomes associated with the use of this robotic technique. METHODS: We present a retrospective review and analysis of data collected from a 16-year experience of a single surgeon using a robotic surgical system and technique for TOS surgery. From the initial design of an endoscope attached to a microvideo camera in 1982 to the adoption of the monorobotic arm with integrated voice in 1998, the main objective of the transaxillary approach has always been to improve visualization of congenital cervical anomalies of the scalene muscles. From February 2003 to December 2018, we performed 412 transaxillary decompression procedures using the robotic da Vinci Surgical System. The surgical procedure has been described in further detail and includes the following steps: (1) positioning of the patient into a lateral decubitus position and using a monoarm retractor; (2) creation of a mini-incision in the axillary area and creation and maintenance of the subpectoral anatomic working space; (3) placement of endoscopic ports and engagement of the robotic instrumentation; (4) dissection of extrapleural and intrapleural soft tissue; (5) creation of the "floater" first rib; (6) excision of the cervical bands and first rib; and (7) placement of thoracostomy tubes for drainage and closure of the incisions. RESULTS: None of the patients died, and no patient experienced permanent neurovascular damage of the extremity. Of the 306 patients, 22 (5% of 441 operations) experienced complications. One patient developed postoperative scarring that required a redo operation with a robotic-assisted transaxillary approach. CONCLUSIONS: With its three-dimensional visual magnification of the anatomic area, the endoscopic robotic-assisted transaxillary approach offers safe and effective management of disabling TOS symptoms. The endoscope facilitates observation of the cervical bands and the mechanism (pathogenesis) of the neurovascular compression that causes TOS, thereby allowing complete excision of the first rib, cervical bands, and scalene muscle. We sought to develop and perfect this robotic approach. The present study was not intended to be a comparative study to nonrobotic TOS surgery.

Cryptococcal empyema treated with tube thoracostomy and intrapleural fibrinolysis.

A 55-year old woman with a history of relapsed T-cell ALL presented with right pleuritic chest pain and decreased breath sounds over the right hemithorax. Imaging of the chest showed loculated effusions. Tube thoracostomy was performed with intrapleural application of alteplase and dornase alpha over a 3-day period. Repeat imaging demonstrated a marked decrease in the volume of the effusion. In most prior published cases of pleural cryptococcosis, surgical drainage was required in addition to prolonged antifungal agents. More than 50% of patients with cryptococcal infection have severe underlying disease or immunodeficiency state making them high risk for surgery. This is the first case to our knowledge of cryptococcal empyema successfully treated with tube thoracostomy and intrapleural fibrinolysis.

Effectiveness and safety of small-bore tube thoracostomy (≤20 Fr) for chest trauma patients: A retrospective observational study.

INTRODUCTION: Tube thoracostomy is an important treatment for traumatic hemothorax and pneumothorax. The optimal tube diameter remains unclear. To reduce invasiveness, we use small-bore chest tubes (≤20 Fr) for all trauma patients for whom tube thoracostomy is indicated in our emergency department (ED). The aim of this study was to investigate the effectiveness and safety of small-bore tube thoracostomy for traumatic hemothorax or pneumothorax. METHOD: We conducted a retrospective observational study at a single emergency medical center. This study included adult patients (≥18 years old) who had undergone tube thoracostomy for chest trauma in the ED during the 5 years from October 2013 to September 2018. We used 20 Fr chest tubes or 8 Fr pigtail catheters. The examined outcome was tube-related complications, such as tube obstruction, retained hemothorax, and unresolved pneumothorax. RESULTS: A total of 107 tube thoracostomies were performed in 102 patients. The mean Injury Severity Score of these patients was 17.8 (±9.6), and the mean duration of the tube placement period was 3.9 days (±1.8). Eight patients developed tube-related complications (7.8%) (retained hemothorax: 4 patients (3.9%), unresolved pneumothorax: 4 patients (3.9%)). None of these cases were caused by tube obstruction. Although the drainage itself was effective, they underwent definitive invasive interventions to stop bleeding or air leak. CONCLUSION: Our study showed that the use of small-bore (≤20 Fr) chest tubes to treat traumatic hemothorax/pneumothorax achieved the purposes of tube thoracostomy. It might be possible to safely manage chest trauma with small-bore chest tubes.

Too Big, Too Small or Just Right? Why the 28 French Chest Tube Is the Best Size.

BACKGROUND: Tube thoracostomy is a commonly performed procedure in trauma patients. The optimal chest tube size is unknown. This study measures chest tube drainage in a controlled laboratory setting and compares measured flowrates to those predicted by the Hagen-Poiseuille equation. MATERIALS AND METHODS: A model of massive hemothorax was created, consisting of a basin containing synthetic blood substitute (aqueous Glycerin and Xanthan gum) and a standard pleur-evac setup at -20 cm H2O suction. Flow measurements were calculated by measuring the time to drain 2L of blood substitute from the basin. Chest tube sizes tested were 20F, 24F, 28F, 32F, and 36F. Thoracostomy opening was modeled using custom built device that represents two ribs, with the distance between varied 2 to 12 mm. Flowrate increases were compared against predicted increases according to the Hagen-Poiseuille equation. Percent of predicted increase was calculated, both incremental increase and using 20F tube benchmark. RESULTS: All tubes were occluded at a 2 mm thoracostomy opening. At 3 mm, 32F and 36F were occluded while smaller tubes were patent. Tubes 28F and larger exhibited high speed and consistent flowrates, even after decreasing thoracostomy opening down to 7 mm, while flowrates rapidly decreased at opening smaller than 7 mm. Smaller 24F and 20F tubes exhibited highly variable flowrates through the system. Maximum flowrates were 21.7, 36.8, 49.6, 55.6, and 61.0 mL/s for 20F-36F tubes, respectively. The incremental increase in flow ratio for increasing chest tube size was 1.69 (20F to 24F), 1.35 (24F to 28F), 1.12 (28F to 32F), and 1.10 (32F to 36F). CONCLUSIONS: The 28F chest tube exhibited high and consistent velocity, while smaller tubes were slower and more variable. Larger tubes offered only slightly higher flowrates. The 28F is a good balance of reasonable size and high flowrate and is likely the optimal size for most clinical applications.

Thoracoacromial artery injury after tube thoracostomy for pneumothorax.

In this case, a patient presented in a delayed fashion after blunt trauma is found to have a large left-sided pneumothorax, and tube thoracostomy is performed. After placement of the apically oriented tube, he developed haemothorax. CT imaging showed an area of questionable extravasation from the left subclavian artery, directly anterior to the thoracostomy tube. His haemothorax was refractory to adequate drainage with a new thoracostomy tube. He ultimately required angiography, coil embolisation and covered stent placement, followed by thoracoscopic evacuation of the haemothorax.

Comparison of 10- versus 14-gauge angiocatheter for treatment of tension pneumothorax and tension-induced pulseless electrical activity with hemorrhagic shock: Bigger is still better.

BACKGROUND: Little is known regarding the effect of hemorrhagic shock on the diagnosis and treatment of tension pneumothorax (tPTX). Recently, the Tactical Combat Casualty Care guidelines included the 10-gauge angiocatheter (10-g AC) as an acceptable alternative to the 14-g AC. This study sought to compare these two devices for decompression of tPTX and rescue from tension-induced pulseless electric activity (tPEA) in the setting of a concomitant 30% estimated blood volume hemorrhage. METHODS: Following a controlled hemorrhage, carbon dioxide was insufflated into the chest to induce either tPTX or tPEA. Tension pneumothorax was defined as a reduction in cardiac output by 50%, and tPEA was defined as a loss of arterial waveform with mean arterial pressure less than 20 mm Hg. The affected hemithorax was decompressed using a randomized 14-g AC or 10-g AC while a persistent air leak was maintained after decompression. Successful rescue from tPTX was defined as 80% recovery of baseline systolic blood pressure, while successful return of spontaneous circulation following tPEA was defined as a mean arterial pressure greater than 20 mm Hg. Primary outcome was success of device. RESULTS: Eighty tPTX and 50 tPEA events were conducted in 38 adult Yorkshire swine. There were no significant differences in the baseline characteristics between animals or devices. In the tPTX model, the 10-g AC successfully rescued 90% of events, while 14-g AC rescued 80% of events (p = 0.350). In the tPEA model, the 10-g AC rescued 87% of events while the 14 AC rescued only 48% of events (p = 0.006). CONCLUSION: The 10-g AC was vastly superior to the 14-g AC for return of spontaneous circulation following tPEA in the setting of 30% hemorrhage. These findings further support the importance of larger caliber devices that facilitate rapid recovery from tPTX, particularly in the setting of polytrauma. LEVEL OF EVIDENCE: Therapeutic, level II.

The Evolution of Surgical Management for Children and Young Adults With Spontaneous Pneumothorax.

BACKGROUND: Few studies have analyzed pediatric spontaneous pneumothorax (SPTX) nationally. We sought to better define this patient population and explore the evolution of surgical management. METHODS: Patients (10-20 y old) with an International Classification of Diseases, Ninth Revision diagnosis of SPTX were identified within the Kids' Inpatient Database for the years 2006, 2009, and 2012. Diagnoses and procedures were analyzed by International Classification of Diseases, Ninth Revision codes. National estimates were obtained using case weighting. RESULTS: There were 11,792 pediatric SPTX hospitalizations, and patients were predominantly male (84.0%), non-Hispanic white (69.0%), with a mean age of 17.2 y (95% confidence interval, 17.2-17.3). Overall, 52.5% underwent tube thoracostomy as the primary intervention, and more than one-third had a major surgical procedure (34.9%). From 2006 to 2012, there was an increase in bleb excisions from 81.1% to 86.9% and an increase in mechanical pleurodesis from 64.2% to 69.0%. There was a significant change from a predominantly open thoracotomy approach in 2006 (76.1%) to a video-assisted thoracoscopic approach in 2012 (89.3%). CONCLUSIONS: Pediatric admission for SPTX results in tube thoracostomy in more than half of the cases and surgery in approximately one-third of the cases. Surgical intervention has changed to a more minimally invasive approach during the last decade, and counseling to patients and their families should reflect these updated management strategies. LEVEL OF EVIDENCE: III.

Evaluation of Jackson-Pratt Thoracostomy Drains Compared with Traditional Trocar Type and Guidewire-Inserted Thoracostomy Drains.

A restrospective study was performed to evaluate the efficacy of and complications among Jackson-Pratt (JP) drains placed as thoracostomy drains, traditional trocar type (TRO) thoracostomy drains, and guidewire (GW)-inserted thoracostomy drains that were placed in open fashion during thoracotomy. Medical records of 65 canine and feline patients who underwent thoracic surgery were evaluated. Dogs and cats who underwent thoracotomy and had a chest drain placed intraoperatively were included. Data retrieved from medical records included signalment, body weight, diagnosis, surgical approach, surgical procedure, type of thoracostomy drain, postoperative analgesia, duration of thoracostomy drain, and postoperative complications. The incidence of complications and number of medications used in pain protocols were compared among types of thoracostomy drains. JP (n = 31), TRO (n = 25), and GW (n = 9) thoracostomy drains were placed in 65 patients. Ten minor (15.3%) and four major (6.2%) complications occurred. Cases with JP thoracostomy drains were significantly less likely to have complications (2 minor, 1 major) than cases with TRO thoracostomy drains (8 minor, 3 major, P = .009). There were no differences in the number of major complications when comparing all three drains individually (P = .350). JP drains and GW drains can be considered as an alternative to traditional TRO thoracostomy drains.

Clamping trials prior to thoracostomy tube removal and the need for subsequent invasive pleural drainage.

BACKGROUND: There is little evidence supporting or refuting clamping trials, a period of clamping thoracostomy tubes prior to removal. We sought to evaluate whether clamping trials reduce the need for subsequent pleural drainage procedures. METHODS: We conducted a retrospective cohort study of trauma patients who underwent tube thoracostomy during 2009-2015. We compared patients who underwent clamping trials to those who did not, adjusting for confounders. The primary outcome was subsequent ipsilateral pleural drainage within 30 days. RESULTS: We evaluated 214 clamping trial and 285 control patients. Only two of 214 patients failed their clamping trial and none developed a tension pneumothorax [0.0% (95% CI 0.0-1.7%)]. Clamping trials were associated with fewer pleural drainage procedures [13 (6%) vs. 33 (12%); adjusted OR 0.41 (95% CI 0.20-0.84)]. CONCLUSIONS: A clamping trial prior to thoracostomy tube removal seems to be safe and was associated with less likelihood of a subsequent pleural drainage procedure.

Using cable ties to connect thoracostomy tubes to drainage devices decreases frequency of unplanned disconnection.

OBJECTIVES: Thoracostomy tube (TT) connection to drainage device (DD) may be unintentionally disconnected, potentiating complications. Tape may strengthen this connection despite minimal data informing optimal practice. Our goal was to analyze the utility of cable ties for TT to DD connection. METHODS: On April 1, 2015, our trauma center supplanted use of tape or nothing with cable ties for securing TT to DD connection. We abstracted trauma registry patients with TTs placed from March 1, 2014 to May 31, 2016 and dichotomized as prior ("BEFORE") and subsequent ("AFTER") to the cable tie practice pattern change. We analyzed demographics, TT-specific details and outcomes. Primary outcome was TT to DD disconnection. Secondary outcomes included TT dislodgement from the chest, complications, length of stay (LOS), mortality, number of TTs placed and TT days. RESULTS: 121 (83.4% of abstracted) patients were analyzed. Demographics, indications for TT and operative rate were similar for BEFORE and AFTER cohorts. ISS was lower BEFORE (14.12 ± 2.35 vs 18.21 ± 2.71, p = 0.022); however, RTS and AIS for chest were similar (p = 0.155 and 0.409, respectively). TT to DD disconnections per TT days were significantly higher in the BEFORE cohort [6 (2.8%) vs. 1 (0.19%), p = 0.003], and dislodgements were statistically similar [0 vs 3 (0.57%), p = 0.36]. LOS, initial TTs placed and days per TT were similar, and median and mode of days per TT were the same. CONCLUSIONS: Cable ties secure connections between TT and DDs with higher fidelity compared to tape or nothing but may increase rates of TT dislodgement from the chest.

Chest Tube Insertion Among Surgical and Nonsurgical Trainees: How Skilled Are Our Residents?

BACKGROUND: Competency-based medical education has renewed focus on the attainment and evaluation of resident skill. Proper evaluation is crucial to inform educational interventions and identify residents in need of increased training and supervision. Currently, there is a paucity of studies rigorously evaluating resident chest tube insertion skill. MATERIALS AND METHODS: Residents of all training levels before their intensive care unit rotation or currently rotating through the intensive care unit were invited to participate. Trainees inserted a thoracostomy tube on a high-fidelity simulator. Their performances were recorded and scored by blinded raters using the validated TUBE-iCOMPT rubric. Surgical and nonsurgical residents were compared. RESULTS: Forty-nine residents participated; 30 from nonsurgical and 19 from surgical training programs. Overall, trainees were most deficient in the "preprocedural checks" and "patient positioning and local anesthetic" domains. Surgical trainees demonstrated higher chest tube insertion skill than their nonsurgical peers (median total score 88 [interquartile range, 74-90] versus 75 [interquartile range, 66-85], respectively, P = 0.01), particularly in the "patient positioning" and "blunt dissection" domains (P = 0.01 and P = 0.03, respectively). These differences were no longer significant when controlled for experience and Advanced Trauma Life Support certification. CONCLUSIONS: Overall, surgical residents were more skilled than nonsurgical residents in tube thoracostomy placement. Relative skill deficits within the domains of chest tube insertion have also been identified among residents of different specialties. These areas can be targeted with educational interventions to improve resident performance, and ultimately, patient safety.

Prehospital needle thoracostomy: What are the indications and is a post-trauma center arrival chest tube required?

OBJECTIVE: This study examined the indications for prehospital needle thoracostomy (pNT), the need for tube thoracostomy (TT) following pNT, and the outcomes of patients who underwent pNT. METHODS: This study is a retrospective chart review of patients who underwent pNT prior to trauma center arrival. Patients were identified from the trauma registry and a quality improvement (QI) database from 9/2014-9/2018. RESULTS: 59 patients underwent 63 pNTs during the time period. The indication for pNT was "hypotension" in only 5 patients (7.9%). A CT chest was obtained on 51 NT attempts with the catheter in place. In 48 (94.1%) NT attempts, the catheter was not in the pleural space. 44 (69.4%) TTs were placed on admission date. CONCLUSION: In patients undergoing pNT, hypotension was rarely the indication. Additionally, CT identified the catheter within the pleural space in only 3 (5.8%) NT attempts. TT placement was performed in 79.3% of NT attempts.

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.

ThoraSite: A device to improve accuracy of lateral decompression needle and chest tube placement.

BACKGROUND: Multiple reports have detailed an unacceptably high error rate in the siting of decompression needles and tubes and describe associated iatrogenic injuries. The objective of the current study was to measure the accuracy of the novel ThoraSite template for identifying an acceptable intercostal space (ICS) for lateral needle or tube thoracostomy. METHODS: Two trained operators used the ThoraSite to place radiopaque needles in the left and right lateral chests of 12 cadavers. An independent radiologist reviewed fluoroscopy images to determine the primary outcome: the ICS in which each needle was placed. Secondary outcomes were ICS's palpable through ThoraSite's Safe Zone; needle placement relative to the anterior axillary line (AAL) and midaxillary line (MAL); and percent correct placement (defined as the third, fourth, or fifth ICS from 1 cm anterior to the AAL to 1 cm posterior to the MAL). RESULTS: The six female and six male cadavers spanned 4 ft and 11 inches (150 cm) to 6 ft and 7 inches (201 cm), 80 lb (36 kg) to 350 lb (159 kg), and 16 kg/m to 42 kg/m body mass index. All 24 needles were placed in either the third (4 [17%] of 24 needles), fourth (10 [42%] of 24 needles), or fifth ICS (10 [42%] of 24 needles). In 10 (42%) of 24 assessments, two ICSs were palpable in ThoraSite's Safe Zone. All palpable ICSs were either the third (8 [24%] of 34), fourth (15 [44%] of 34); or fifth ICS (11 [32%] of 34). Twenty-three (96%) of 24 needles were inserted from 1 cm anterior to the AAL to 1 cm posterior to the MAL. Twenty-three (96%) of 24 needle placements were correct. CONCLUSION: ThoraSite use was associated with needle placement in the third, fourth, or fifth ICS in an area roughly spanning the AAL to MAL in anatomically diverse cadavers. By facilitating appropriate needle/tube placement, ThoraSite use may decrease iatrogenic injuries. Future study involving representative users may be useful to further evaluate ThoraSite accuracy. LEVEL OF EVIDENCE: Therapeutic and care management, level IV.

Do It Better: Cross Mattress for Chest Drain Insertion Site Security Offers Quality Outcome in Chest Trauma Patients Required Tube Thoracostomy.

We examined the hypothesis that the cross mattress for chest drain insertion site security is better than that of polypropylene horizontal mattress in chest trauma patient required tube thoracostomy at the Department of Casualty Surgery, Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2016 to June 2016. Accordingly we prospectively studied 50 consecutive patients who needed chest tube insertion. In 25 consecutive cases chest drain insertion site was secured with polypropylene horizontal mattress technique (Control- Group A) and another 25 consecutive patients had a cross-mattress with non-absorbable suture materials (Experimental- Group B). All chest tubes were inserted into the triangle of safety to following the BTS guideline. A baseline x-ray chest was compared with post-procedure chest x-ray. Male preponderance and young adults were comprised in both the groups; mean age in Group A and Group B was 38.7±15.5 and 37.3±14.1 respectively. Haemo-pneumothorax was the most common cause of tube thoracostomy among the trauma victims. This study shows that, polypropylene horizontal mattress results in increased chest tube site infection 52% in Control Group vs. 12% in Experimental Group (p=0.002). Although there was similar incidence of blood loss between the groups, the length of Hospital stay was significantly higher in Control Group. We conclude that cross mattress for chest drain insertion site security showed a better clinical outcome, less wound complications and less hospitalization.