An Analysis of Tube Thoracostomy in Combat Implications for Improved Prehospital Recognition and Treatment.

BACKGROUND: Thoracic trauma occurs frequently in combat and is associated with high mortality. Tube thoracostomy (chest tube) is the treatment for pneumothorax resulting from thoracic trauma, but little data exist to characterize combat casualties undergoing this intervention. We sought to describe the incidence of these injuries and procedures to inform training and materiel development priorities. METHODS: This is a secondary analysis of a Department of Defense Trauma Registry (DoDTR) data set from 2007 to 2020 describing prehospital care within all theaters in the registry. We described all casualties who received a tube thoracostomy within 24 hours of admission to a military treatment facility. Variables described included casualty demographics; abbreviated injury scale (AIS) score by body region, presented as binary serious (=3) or not serious (<3); and prehospital interventions. RESULTS: The database identified 25,897 casualties, 2,178 (8.4%) of whom received a tube thoracostomy within 24 hours of admission. Of those casualties, the body regions with the highest proportions of common serious injury (AIS >3) were thorax 62% (1,351), extremities 29% (629), abdomen 22% (473), and head/neck 22% (473). Of those casualties, 13% (276) had prehospital needle thoracostomies performed, and 19% (416) had limb tourniquets placed. Most of the patients were male (97%), partner forces members or humanitarian casualties (70%), and survived to discharge (87%). CONCLUSIONS: Combat casualties with chest trauma often have multiple injuries complicating prehospital and hospital care. Explosions and gunshot wounds are common mechanisms of injury associated with the need for tube thoracostomy, and these interventions are often performed by enlisted medical personnel. Future efforts should be made to provide a correlation between chest interventions and pneumothorax management in prehospital thoracic trauma.

Is there a change in the view of treatment for primary spontaneous pneumothorax?: The effect of thoracic CT and autologous blood pleurodesis: a retrospective cohort study.

This study investigated recurrence rates and treatment efficacy based on tomographic findings during a long-term follow-up after primary spontaneous pneumothorax (PSP) treatment. We retrospectively analyzed patients with PSP treated at our hospital between 2003 and 2020. Patients were categorized into 2 groups based on computed tomography (CT) findings: group 1 (no bulla/bleb) and group 2 (bullae-bleb <3 cm). Data on demographics, recurrence, treatment methods, and outcomes were also collected and compared. A total of 251 PSP cases were evaluated, predominantly male (93.6%) with a mean age of 29.23 ±â€…1.14 years. Most cases (57%) occurred on the right side. Recurrence rates were highest within the first year (77.8%), with the first and second recurrences occurring at rates of 26% and 27.3%, respectively. In group 1 (n = 117), conservative treatment was applied in 15 cases, tube thoracostomy in 81, autologous blood pleurodesis (ABP) in 19, and surgery in 12. Recurrence rates were 46.6%, 21%, 5.3%, and 8.3%, respectively. In group 2 (n = 134), the recurrence rates were 50%, 32.7%, 20%, and 3.1%, respectively (P < .001). No mortality was observed for any patient. The treatment groups included conservative (n = 19), thoracostomy (n = 179), ABP (n = 34), and surgical (n = 44) groups. Recurrence rates were 47.3%, 27.4%, 11.8% (group 1: 5.3%, group 2: 20%, P = .035), and 4.5% (0% vs 6.3%), respectively. ABP effectively reduced recurrence in group 1 PSP patients without bullae or blebs on CT, potentially avoiding surgery. Video-assisted thoracoscopic surgery should be preferred in group 2 cases with bullae or blebs to minimize recurrence. These results underscore the importance of tailoring treatment strategies based on CT findings to optimize PSP management outcomes.

A Novel Technique for Temporally Securing a Chest Tube in a Resource-Limited Environment.

In the prehospital, transport, and resource-limited setting, patients with traumatic hemothorax, pneumothorax, or cardiac arrest require emergency tube thoracostomy for stabilization and transport. With the possibility of multiple patients, limited providers, and inability to commit a 1:1 provider-to-patient ratio for safe tubeless thoracostomies, a chest tube is often the safest option. Mercy Health Life Flight Air Medical program has developed practice over decades using towel clamps and tape to achieve securement rapidly and reliably. We report on this subject as an option for temporarily securing a chest tube in the disaster, resource-poor, prehospital, or critical care transport setting.

Thoracic Ultrasound for Detection of Pneumothorax Following Thoracostomy Tube Removal in Trauma Patients.

INTRODUCTION: Screening for pneumothorax (PTX) is standard practice after thoracostomy tube removal, with postpull CXR being the gold standard. However, studies have shown that point-of-care thoracic ultrasound (POCTUS) is effective at detecting PTX and may represent a viable alternative. This study aims to evaluate the safety and efficacy of POCTUS for evaluation of clinically significant postpull PTX compared with chest x-ray (CXR). METHODS: We performed a prospective, cohort study at a Level 1 trauma center between April and December 2022 comparing the ability of POCTUS to detect clinically significant postpull PTX compared with CXR. Patients with thoracostomy tube placed for PTX, hemothorax, or hemopneumothorax were included. Clinically insignificant PTX was defined as a small residual or apical PTX without associated respiratory symptoms or need for thoracostomy tube replacement while clinically significant PTX were moderate to large or associated with physiologic change. RESULTS: We included 82 patients, the most common etiology was blunt trauma (n = 57), and the indications for thoracostomy tube placement were: PTX (n = 38), hemothorax (n = 15), and hemopneumothorax (n = 14). One patient required thoracostomy tube replacement for recurrent PTX identified by both ultrasound and X-ray. Thoracic ultrasound had a sensitivity of 100%, specificity of 95%, positive predictive value of 60%, and negative predictive value of 100% for the detection of clinically significant postpull PTX. CONCLUSIONS: The use of POCTUS for the detection of clinically significant PTX after thoracostomy tube removal is a safe and effective alternative to standard CXR. This echoes similar studies and emphasizes the need for further investigation in a multicenter study.

Late video-assisted thoracoscopic surgery versus thoracostomy tube reinsertion for retained hemothorax after penetrating trauma, a prospective randomized control study.

BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.

Retreatment after primary spontaneous pneumothoraxes managed with primary tube thoracostomy or surgery.

BACKGROUND AND AIMS: There is a paucity of data on later healthcare visits and retreatments after primary treatment of spontaneous pneumothorax. The main purpose of this study was to describe retreatment rates up to 5 years after primary spontaneous pneumothorax treated with either surgery or tube thoracostomy (TT) at index hospitalization in Finland between 2005 and 2018 to estimate the burden of primary spontaneous pneumothorax on the healthcare system. METHODS: Retrospective registry-based study of patients with primary spontaneous pneumothorax treated with TT or surgery in Finland in 2005-2018. Rehospitalization and retreatment for recurrent pneumothorax and complications attributable to initial treatment were identified. RESULTS: The total study population was 1594 patients. At 5 years, 53.2% (384/722) of TT treated and 33.8% (295/872) of surgically treated patients had undergone any retreatment. Surgery was associated with a lower risk of recurrence than TT (hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.43-0.56, p < 0.001). Male sex was associated with a lower risk of recurrent treatment (HR 0.75, 95% CI 0.63-0.90, p = 0.001). Higher age decreased the risk of recurrent treatment (HR 0.99, 95% CI 0.99-0.99, p < 0.001). At 5 years, 36.0% (260/722) of the TT treated and 18.8% (164/872) of the surgically treated had undergone reoperation at some point. CONCLUSIONS: Reintervention rates and repeat hospital visits after TT and surgery were surprisingly high at long-term follow-up. Occurrences of retreatment and reoperation were significantly higher among primary spontaneous pneumothorax patients treated with TT at index hospitalization than among patients treated with surgery.

Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review.

Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.

Using chest X-ray to predict tube thoracostomy in traumatic pneumothorax: A single-institution retrospective review.

BACKGROUND: Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the "35-mm" rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy. METHODS: We performed a single-institution retrospective review of patients with traumatic PTX from 2018 to 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than 4 hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden's index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression. RESULTS: There were 341 pneumothoraces in 304 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (24.0%) had a TT placed within the first 4 hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0-18.0 mm] vs. 0.0 mm [0.0-2.3 mm] ( p < 0.001)). Chest x-ray PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm. CONCLUSION: Chest x-ray imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the "35-mm rule." In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

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

INTRODUCTION: Retained hemothorax (HTX) is a common complication following thoracic trauma. Small studies demonstrate the benefit of thoracic cavity irrigation at the time of tube thoracostomy (TT) for the prevention of retained HTX. We sought to assess the effectiveness of chest irrigation in preventing retained HTX leading to a secondary surgical intervention. METHODS: We performed a single-center retrospective study from 2017 to 2021 at a Level I trauma center, comparing bedside thoracic cavity irrigation via TT versus no irrigation. Using the trauma registry, patients with traumatic HTX were identified. Exclusion criteria were TT placement at an outside hospital, no TT within 24 hours of admission, thoracotomy or video-assisted thoracoscopic surgery (VATS) prior to or within 6 hours after TT placement, VATS as part of rib fixation or diaphragmatic repair, and death within 96 hours of admission. Bivariate and multivariable analyses were conducted. RESULTS: A total of 370 patients met the inclusion criteria, of whom 225 (61%) were irrigated. Patients who were irrigated were more likely to suffer a penetrating injury (41% vs. 30%, p = 0.03) and less likely to have a flail chest (10% vs. 21%, p = 0.01). On bivariate analysis, irrigation was associated with lower rates of VATS (6% vs. 19%, p < 0.001) and retained HTX (10% vs. 21%, p < 0.001). The irrigated cohort had a shorter TT duration (4 vs. 6 days, p < 0.001) and hospital length of stay (7 vs. 9 days, p = 0.04). On multivariable analysis, thoracic cavity irrigation had lower odds of VATS (adjusted odds ratio, 0.37; 95% confidence interval [CI], 0.30-0.54), retained HTX (adjusted odds ratio, 0.42; 95% CI, 0.25-0.74), and a shorter TT duration ( ß = -1.58; 95% CI, -2.52 to -0.75). CONCLUSION: Our 5-year experience with thoracic irrigation confirms findings from smaller studies that irrigation prevents retained HTX and decreases the need for surgical intervention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Efficacy, Safety, and Complications of Pigtail Thoracostomy for the Treatment of Pediatric Pleuropneumonia.

OBJECTIVE: Pigtail thoracostomy (PT) has become the mainstay technique for the drainage of pediatric pleuropneumonic effusions (PLPe). However, its efficacy and complication profile has been questioned when compared with video-assisted thoracoscopic surgery and larger bore traditional tube thoracostomy. The aim of this study was to assess the efficacy, safety, and complications associated with PT. METHODS: A cross-sectional study at a freestanding tertiary children's hospital. We extracted the medical records of all children aged younger than 18 years treated with PT for PLPe from June 2016 to June 2020. The primary efficacy outcome was treatment failure defined as the need for a repeat drainage procedure, thoracostomy, or video-assisted thoracoscopic surgery. Secondary efficacy outcomes were length of hospital stay (LOS) and duration of in situ PT. The primary safety outcomes were adverse events during or after insertion. We also recorded any associated complications. RESULTS: During the study period, 55 children required PT. The median age was 25 months (interquartile range, 14-52) and 58.2% were boys. Eight (14.4%) were bacteremic or in septic shock. There were no adverse events related to insertion. Forty-two (76.3%) children were treated with fibrinolysis. There were 2 (3.6%) treatment failures. The median LOS and PT durations were 13 and 4 days (interquartile ranges, 10-14.8, 3-6.7), respectively. Eight (14.4%) children experienced complications that were nonoperatively managed. CONCLUSIONS: Our findings suggest that PT drainage offers a safe and highly effective option for managing PLPe and carries a very low failure rate.

Validation of the 35-mm rule in traumatic pneumothorax in an Asian population.

OBJECTIVES: Thoracic injury crucially threatens human health. Recent studies have suggested using computed tomography (CT) to observe traumatic pneumothorax (PTX). However, cross-ethnic validation is required to overcome potential barriers for the global application of this method. This study aimed to validate the 35-mm rule in traumatic PTX in a Korean population. METHODS: Data from the institutional registry were analyzed, and chest CT images were reviewed. Factors for observation failure were evaluated via logistic regression analysis, and a receiver-operating curve was created to calculate the optimal cutoff value. RESULTS: In total, 286 participants were included in this study. The average PTX size was 8.2 (3.2-26.5) mm, and 210 of 213 (95.3%) initially observed patients with a PTX size of ≤35 mm successfully completed the safety observation. Multivariate regression analysis revealed that a PTX size of >35 mm is associated with observation failure and suggested a cutoff of 24.5 mm. CONCLUSION: Most patients with traumatic PTX of ≤35 mm on CT had undergone successful 4-h observation without thoracostomy. Additionally, PTX of >35 mm was an independent risk factor for observation failure. Considering the lower optimal cutoff value and high failure rates observed in this study, the current guidelines need modifications.

Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy.

INTRODUCTION: The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature. METHODS: Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan. RESULTS: Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63 years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4). CONCLUSION: A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.

[Crucial Techniques for Chest Tube Placement and Postoperative Management].

Postoperative management of thoracic surgery with an indwelling chest tube is common, and knowledge about it is essential. A postoperative chest tube has four roles:1) to reinflate the lung, 2) to observe the condition of the thoracic cavity and acquire information regarding the outcomes, 3) to prevent complications, and 4) to treat pulmonary air leaks and empyema (chemical pleurodesis et ct). Although postoperative complications have decreased in recent years following advances in video-assisted thoracoscopic surgery( VATS) and devices such as stapling devices and vascular sealing systems (VSS), postoperative chest tube placement is still common. Therefore, a thorough knowledge of chest tube management is extremely important in thoracic surgery. Here, we have described, in detail, the management of a postoperative chest tube at our hospital.

[Postoperative Complications of Open Window Thoracostomy:Report of a Case].

While open window thoracostomy is used to treat empyema with a high rate of infection control, it is an invasive procedure that leads to a decline in the quality of life. An 80-year-old man who had undergone wedge resection for pulmonary nodules subsequently developed postoperative empyema and underwent open window thoracostomy. After thoracostomy, the patient developed several complications, including bleeding from the lung surface and air leakage. Window closure was planned at this time;however, the plan was scuttled due to his low nutritional status and pulmonary air leakage. After the patient's condition improved with persistent conservative treatment, window closure was performed, and he overcame his complications. Patients with postoperative empyema requiring thoracostomy are at a high risk of developing postoperative complications. Therefore, it is important to manage the patients' condition persistently so that they can receive window closure at an appropriate time.

DraiNet: AI-driven decision support in pneumothorax and pleural effusion management.

OBJECTIVE: This study presents DraiNet, a deep learning model developed to detect pneumothorax and pleural effusion in pediatric patients and aid in assessing the necessity for tube thoracostomy. The primary goal is to utilize DraiNet as a decision support tool to enhance clinical decision-making in the management of these conditions. METHODS: DraiNet was trained on a diverse dataset of pediatric CT scans, carefully annotated by experienced surgeons. The model incorporated advanced object detection techniques and underwent evaluation using standard metrics, such as mean Average Precision (mAP), to assess its performance. RESULTS: DraiNet achieved an impressive mAP score of 0.964, demonstrating high accuracy in detecting and precisely localizing abnormalities associated with pneumothorax and pleural effusion. The model's precision and recall further confirmed its ability to effectively predict positive cases. CONCLUSION: The integration of DraiNet as an AI-driven decision support system marks a significant advancement in pediatric healthcare. By combining deep learning algorithms with clinical expertise, DraiNet provides a valuable tool for non-surgical teams and emergency room doctors, aiding them in making informed decisions about surgical interventions. With its remarkable mAP score of 0.964, DraiNet has the potential to enhance patient outcomes and optimize the management of critical conditions, including pneumothorax and pleural effusion.

Clinical outcomes of traumatic pneumothoraces undergoing conservative management following detection by prehospital physicians.

OBJECTIVE: To describe the clinical and transport characteristics of patients diagnosed with a suspected traumatic pneumothorax and managed conservatively by prehospital medical teams including secondary deterioration during transfer and the subsequent rate of in-hospital tube thoracostomy. METHODS: Retrospective observational study of all adult trauma patients diagnosed with a suspected pneumothorax on ultrasound and managed conservatively by their treating prehospital medical team between 2018 and 2020. Descriptive analysis was performed comparing patients who did and did not receive in-hospital tube thoracostomy. RESULTS: In total, 181 patients were diagnosed with suspected traumatic pneumothoraces on prehospital ultrasound of which 75 (41.4%) were managed conservatively by their treating medical team whilst 106 (58.6%) underwent pleural decompression. There were no recorded cases of emergent pleural decompression required in transit. Of the 75 conservatively managed patients, 42 (56%) had an intercostal catheter (ICC) placed within four hours of hospital arrival and another nine (17.6%) had an ICC placed between four- and 24-hours post-hospital arrival. There was no significant difference in prehospital clinical characteristics between patients who did and did not receive an in-hospital ICC. The detection of a pneumothorax on the initial chest x-ray and larger pneumothorax volume visualised on computed tomography imaging were significantly more common in patients receiving in-hospital ICCs. Aviation factors including flight altitude and duration of flight were not associated with subsequent in-hospital tube thoracostomy. CONCLUSION: Prehospital medical teams can safely identify patients who have a traumatic pneumothorax and can be transported to hospital without pleural decompression. Patient characteristics at the time of hospital arrival combined with the size of pneumothorax identified on imaging appear most likely to influence subsequent urgent in-hospital tube thoracostomy placement.

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.

Evaluating emergency department tube thoracostomy: A single-center use of trauma video review to assess efficiency and technique.

BACKGROUND: Emergency department tube thoracostomy is a common procedure; however, assessing procedural skills is difficult. We sought to describe procedural variability and technical complications of emergency department tube thoracostomy using trauma video review. We hypothesized that factors such as hemodynamic abnormality lead to increased technical difficulty and malpositioning. METHODS: Using trauma video review, we reviewed all emergency department tube thoracostomy from 2020 to 2022. Patients were stratified into hemodynamically abnormal (systolic blood pressure <90 or heart rate >120) and hemodynamically normal (systolic blood pressure ≥90 or heart rate ≤120). Emergency department tube thoracostomies outside of video-capable rooms, with incomplete visualization, or in patients undergoing cardiopulmonary resuscitation or resuscitative thoracotomy were excluded. The primary outcome was a procedure score modified from the validated tool ranging from 0 to 11 (higher score indicating better performance). Also measured were procedural times to (1) decision to place, (2) pleural entry, and (3) procedure completion. Postprocedure x-ray and chart review were used to determine accuracy. RESULTS: In total, 51 videos met the inclusion criteria. The median age was 34 [interquartile range 24-40] years, body mass index 25.8 [interquartile range 21.8-30.7], predominately male (75%), blunt injury (57%), with Injury Severity Score of 22 [14.5-41]. The median procedure score was 9 [7-10]. Emergency department tube thoracostomies in patients with abnormal hemodynamics had significantly lower procedure scores (8 vs 10, P < .05). Hemodynamically abnormal patients had significantly shorter times from decision to proceed to pleural entry (4.05 vs 8.25 minutes, P < .001), and to completion (6.31 vs 14.23 minutes, P < .001). The most common complication was malpositioning (35.1%), with no significant difference noted when comparing hemodynamically normal and abnormal patients (P = .41). CONCLUSION: Using trauma video review we identified significant procedural variability in emergency department tube thoracostomy, mainly that hemodynamic abnormality led to lower proficiency scores and increased malpositioning. Efforts are needed to define procedural benchmarks and evaluation in the context of patient outcomes. Using this technology and methodology can help establish procedural norms.

A Narrative Review of Traumatic Pneumothorax Diagnoses and Management.

BACKGROUND: Correct identification and rapid intervention of a traumatic pneumothorax is necessary to avoid hemodynamic collapse and subsequent morbidity and mortality. The purpose of this clinical review is to summarize the evaluation and best treatment strategies to improve outcomes in combat casualties. Blunt, explosive, and penetrating trauma are the 3 etiologies for causing a traumatic pneumothorax. Blunt trauma tends to be more common, but all etiologies require similar treatment. The current standard to diagnose pneumothorax is through imaging to include ultrasound, chest x-ray, or computed tomography. A physical exam aids in the diagnosis especially when few other resources are available. Recent studies on the treatment of a small, closed pneumothorax involve conservative care, which includes close observation of the patient and monitoring supplemental oxygen. For a large, closed pneumothorax, conservative treatment is still a possible option, but manual aspiration may be required. Less often, a needle or tube thoracostomy is needed to reinflate the lung. Large, open pneumothoraxes require the most invasive treatment with current guidelines recommending tube thoracostomy. More invasive management options can result in higher rates of complications. Given the significant variability in practice patterns, most notable in resource limited settings, the areas for potential research are presented.

Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces.

BACKGROUND: Traumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy. METHODS: We retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean. RESULTS: Of patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema. CONCLUSIONS: Select patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients.