Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement.

BACKGROUND: Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management. METHODS: Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression. RESULTS: Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05). CONCLUSION: The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients. LEVEL OF EVIDENCE: Prognostic, level IV.

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.

Readmission for pleural space complications after chest wall injury: Who is at risk?

BACKGROUND: Little is known about patient characteristics predicting postdischarge pleural space complications (PDPSCs) after thoracic trauma. We sought to analyze the patient population who required unplanned hospital readmission for PDPSC. METHODS: Retrospective review of adult patients admitted to a Level I Trauma Center with a chest Abbreviated Injury Scale (AIS) score of 2 or greater between January 2015 and August 2020. Those readmitted within 30 days of index hospitalization discharge for PDPSC were compared with those not readmitted. Demographics, injury characteristics, surgical procedures, imaging, and readmission data were retrieved. RESULTS: Out of 17,192 trauma evaluations, 3,412 (19.8%) suffered a chest AIS score of 2 or greater injury and 155 experienced an unplanned 30-day hospital readmission. Of those, 49 (1.4%) were readmitted for the management of PDPSC (readmit PDPSC) and were compared with patients who were not readmitted (no readmit, n = 3,257). The readmit PDPSC group was significantly older age, heavier, comprised of fewer men, and suffered a higher mean chest AIS score. The readmit PDPSC group had a significantly higher incidence of rib fractures, flail chest, pneumothorax, hemothorax, scapula fractures, and a higher rate of tube thoracostomy placement during index admission. The discharge chest X-ray in the readmit PDPSC group demonstrated a pleural space abnormality in 36 (73%) of patients. Mean time to readmission was 10.2 (7.2) days, and hospital length of stay on readmission was 5.8 (3.7) days. Pleural effusion was the most common readmission diagnosis (44 [90%]), and 42 (86%) required tube thoracostomy. CONCLUSION: We describe the subset of chest wall injury patients who require hospital readmission for PDPSC. Characteristics from index hospitalization associated with PDPSC include older age, female sex, heavier weight, presence of rib fractures, pleural space abnormality, scapular fracture, and chest tube placement. Further studies are needed to characterize this at-risk chest wall injury population, and to determine what interventions can facilitate outpatient management of postdischarge pleural space complications and mitigate readmission risk. LEVEL OF EVIDENCE: Prognostic and epidemiologic, Level IV; Care management, Level V.

Safety and Performance of Transbronchial Cryobiopsy for Parenchymal Lung Lesions.

BACKGROUND: Despite advances in technology, the bronchoscopic diagnosis of parenchymal pulmonary lesions (PPLs) remains difficult to achieve. Transbronchial lung cryobiopsy (TLCB) offers the potential for larger samples with improved diagnostic yield; however, a paucity of data exists describing its safety and usefulness for the diagnosis of PPL. RESEARCH QUESTION: What is the safety profile of TLCB for PPL? STUDY DESIGN AND METHODS: An observational, retrospective, multicenter cohort study enrolled patients without endobronchial disease undergoing TLCB of PPL from 2015 through 2019. All procedures were performed using both rigid and flexible bronchoscopy with a flexible cryoprobe. Complication rates, including bleeding and pneumothorax rates, were collected. Bleeding was graded on a scale from 0 (trace) to 4 (requiring surgical intervention) with a grade of ≥ 3 considered clinically significant. Pneumothorax, tube thoracostomy placement, diagnostic yield, and need for subsequent interventions were recorded. RESULTS: One thousand twenty-four patients underwent TLCB. One hundred eighty-eight patients (18%) experienced bleeding; in 36 patients (3.5%), the bleeding was clinically significant. Sixty-eight patients (6.6%) demonstrated a pneumothorax and 64 patients (6.3%) required drainage with tube thoracostomy. All chest drains were removed within 4 days, and no cases of prolonged air leak occurred. A definitive diagnosis was achieved in 932 patients (91%). Adenocarcinoma (46%) and metastatic disease (21%) were the most common diagnoses. INTERPRETATION: TLCB showed an acceptable safety profile and diagnostic yield for the evaluation of PPL in this large retrospective cohort. Prospective clinical trials are underway to validate these findings further.

Patterns of pediatric thoracic penetrating injuries: A single-trauma-center experience in Riyadh, Saudi Arabia.

OBJECTIVES: To review the patterns and outcomes of pediatric thoracic penetrating injuries in a level one trauma center. METHODS: Retrospective chart review of pediatric patients who presented to the King Abdulaziz Medical City Emergency Department (KAMC-ED), Riyadh, Saudi Arabia with thoracic penetrating injury from 2001 to 2016. RESULTS: Eighty-nine patients had a penetrating injury to the thorax were identified. The mean age was 15.5 ± 3.6 years. The mean length of hospital stay was 3.87 ± 5 days. The most common cause was stabbing followed by gunshot. Isolated injury to the thorax was seen in 58 patients. The most common injuries sustained were pneumothorax and hemothorax. In the ED, tube thoracostomy was required in 65 patients, endotracheal intubation in 12, blood transfusion in 14, massive blood transfusion in one, pericardiocentesis in one, and ED thoracotomy in 2. Only 15 patients required surgical intervention. The overall mortality rate was 3.4%. Death was mainly caused by associated injuries to the heart, aorta and/or inferior vena cava. CONCLUSION: Thoracic injuries represent 25% of the overall penetrating traumas in pediatric age group. Most sustained injuries can be safely managed non-operatively, with a favorable outcome. Prompt resuscitation and intervention are required to identify and manage life-threatening injuries.

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.

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.

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.

A descriptive analysis of the epidemiology and management of paediatric traumatic out-of-hospital cardiac arrest.

AIM: Paediatric traumatic out-of-hospital cardiac arrest (OHCA) is a rare event with few survivors. We examined long-term trends in the incidence and outcomes of paediatric traumatic OHCA and explored the frequency and timing of intra-arrest interventions. METHODS: We retrospectively analysed data from the Victorian Ambulance Cardiac Arrest Registry for cases involving traumatic OHCA in patients aged ≤16 years arresting between January 2000 to December 2017. Trends were assessed using linear regression and a non-parametric test for trend. RESULTS: A total of 292 cases were attended by emergency medical services (EMS), of which 166 (56.9%) received an attempted resuscitation. The overall incidence of EMS-attended cases was 1.4 cases per 100,000 person-years, with no significant changes over time. Unadjusted outcomes also remained unchanged, with 23.5% achieving return of spontaneous circulation and 3.7% surviving to hospital discharge. The frequency of trauma-specific interventions increased between 2000-2005 and 2012-2017, including needle thoracostomy from 10.5% to 51.0% (p trend <0.001), crystalloid administration from 31.6% to 54.9% (p trend = 0.004) and blood administration from 0.0% to 6.3% (p trend = 0.01). The median time from emergency call to the delivery of interventions were: 12.9 min (IQR: 8.5, 20.0) for cardiopulmonary resuscitation, 19.7 min (IQR: 10.7, 39.6) for external haemorrhage control, 29.8 min (IQR: 22.0, 35.4) for crystalloid administration and 31.5 min (IQR: 21.0, 38.0) for needle thoracostomy. CONCLUSION: The incidence and outcomes of paediatric traumatic OHCA remained unchanged over an 18 year period. Early correction of reversible causes by reducing delays to the delivery of trauma-specific interventions may yield additional survivors.

Out-of-hospital cardiac arrest following trauma: What does a helicopter emergency medical service offer?

INTRODUCTION: Helicopter emergency medical services (HEMS) are often dispatched to patients in traumatic cardiac arrest (TCA) as they can provide treatments and advanced interventions in the pre-hospital environment that have the potential to contribute to an increased survival. This study, aimed to investigate the added value of HEMS in the treatment of TCA. METHODS: We performed a retrospective cohort study of all patients with a pre-hospital TCA who were attended by a non-urban HEMS (Kent, Surrey and Sussex Air Ambulance trust) between July 1st 2013 and May 1st 2018. We investigated how many patients got return of spontaneous circulation (ROSC) at scene, which HEMS specific advanced interventions were performed in these patients, and how these interventions were related to ROSC. RESULTS: During the study period 263 patients with a TCA were attended by HEMS with an average response time of 30 min [range 13-109]. 51 patients (20%) regained ROSC at scene (28 before- and 23 after arrival of HEMS). The HEMS specific interventions of blood product administration (OR 8.54 [2.84-25.72]), and RSI (2.95 [1.32-6.58]) were positively associated with ROSC. Most patients who had a ROSC had one or more HEMS specific interventions being performed - RSI (n = 19, 37%), blood product administration (n = 32, 62%), thoracostomies (n = 36, 71%) and thoracotomy (n = 1, 2%). HEMS also delivered other important interventions to these patients as IV/IO access (n = 20, 39.2%) and endotracheal intubation without drugs (n = 9, 17.6%). CONCLUSION: HEMS teams should be involved in the treatment of patients with a TCA, even in non-urban areas with prolonged response times, as they provide knowledge and skills that contribute to regaining and maintaining a sustained ROSC in this critically ill and injured cohort of patients.

Pneumomediastinum and pneumopericardium following blunt thoracic trauma: much ado about nothing?

PURPOSE: Pneumomediastinum is the hallmark of intrathoracic aerodigestive trauma, but rare following blunt injury. AIM: review of blunt thoracic trauma (BTC) for the incidence and outcome of patients with pneumomediastinum or pneumopericardium (PM/PC) on Computerised Tomographic scanning. METHODS: Admissions to the level I trauma ICU at IALCH, Durban, ZA following BTC from April 2007 to March 2014. Patients with Chest-CT-scan were analysed. Variables included age, sex, mechanism of injury, and Injury Severity Score (ISS). Specific injury patterns: isolated thoracic trauma, flail chest, bilateral injury and presence of haemothorax or pneumothorax were analysed. RESULTS: Three hundred and eighty-nine patients were included. Males (70.9%) accounted for the majority of patients. The median Injury Severity Score was 32 (IQR 24-41). Motor vehicle collisions accounted for 94% of injury mechanisms. Twenty-three (5.9%) were identified with pneumomediastinum, 6 (1.5%) with both pneumomediastinum and pneumopericardium, and 1 (0.2%) with isolated pneumopericardium. No patient required surgery for thoracic trauma. Increasing age (p < 0.001) and a flail chest (p = 0.005) were significant associations. The mortality rate was almost identical in those with or without air within the mediastinum. No patient died from a missed mediastinal aero-digestive injury. CONCLUSION: The presence of PM/PC following BTC is incidental and benign. Increased injury severity with a flail chest is associated with a significant increase in the presence of free gas within the mediastinum. In the absence of complications, no obvious injury to the intrathoracic aero-digestive tract on CT scanning, and no difference in mortality, a conservative management policy is warranted.

A Survey Assessment of Perceived Importance and Methods of Maintenance of Critical Procedural Skills in Pediatric Emergency Medicine.

OBJECTIVE: The aim of this study was to delineate pediatric emergency medicine provider opinions regarding the importance of, and to ascertain existing processes by which practitioners maintain, the following critical procedural skills: oral endotracheal intubation, intraosseous line placement, pharmacologic and electrical cardioversion, tube thoracostomy, and defibrillation. METHODS: A customized survey was administered to all members of the Listserv for the American Academy of Pediatrics Section on Emergency Medicine. Perceived importance of maintaining critical pediatric procedural skills was measured using a 5-point Likert-type scale. Secondary outcomes included presence and type of mandatory training, availability of on-site backup, and perceived barriers to maintenance of skills. RESULTS: Two hundred sixty-two members (25%) responded representing 106 different institutions, 70% of freestanding children's hospitals that received graduate medical education payments in 2014, and 68% of pediatric emergency medicine fellowship programs. More than 90% of respondents felt it was either very or extremely important to maintain competency for 5 of the 6 critical procedures, but no more than 49% of respondents felt that clinical care alone provided opportunity to maintain skills. The proportion of respondents indicating no mandatory training for each critical procedural skill was as follows: oral endotracheal intubation (23%), intraosseous line placement (30%), pharmacologic cardioversion (32%), electrical cardioversion (32%), tube thoracostomy (40%), and defibrillation (32%). CONCLUSIONS: Critical procedural skills are perceived by emergency providers who care for children as extremely important to maintain. Direct care of pediatric patients likely does not provide sufficient opportunity to maintain these skills. There are widespread deficiencies relating to mandatory maintenance of critical procedural skill training.

Emergency medical dispatch recognition, clinical intervention and outcome of patients in traumatic cardiac arrest from major trauma: an observational study.

OBJECTIVES: The aim of this study is to describe the demographics of reported traumatic cardiac arrest (TCA) victims, prehospital resuscitation and survival to hospital rate. SETTING: Helicopter Emergency Medical Service (HEMS) in south-east England, covering a resident population of 4.5 million and a transient population of up to 8 million people. PARTICIPANTS: Patients reported on the initial 999 call to be in suspected traumatic cardiac arrest between 1 July 2016 and 31 December 2016 within the trust's geographical region were identified. The inclusion criteria were all cases of reported TCA on receipt of the initial emergency call. Patients were subsequently excluded if a medical cause of cardiac arrest was suspected. OUTCOME MEASURES: Patient records were analysed for actual presence of cardiac arrest, prehospital resuscitation procedures undertaken and for survival to hospital rates. RESULTS: 112 patients were reported to be in TCA on receipt of the 999/112 call. 51 (46%) were found not to be in TCA on arrival of emergency medical services. Of the 'not in TCA cohort', 34 (67%) received at least one advanced prehospital medical intervention (defined as emergency anaesthesia, thoracostomy, blood product transfusion or resuscitative thoracotomy). Of the 61 patients in actual TCA, 10 (16%) achieved return-of-spontaneous circulation. In 45 (88%) patients, the HEMS team escorted the patient to hospital. CONCLUSION: A significant proportion of patients reported to be in TCA on receipt of the emergency call are not in actual cardiac arrest but are critically unwell requiring advanced prehospital medical intervention. Early activation of an enhanced care team to a reported TCA call allows appropriate advanced resuscitation. Further research is warranted to determine which interventions contribute to improved TCA survival.

Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study.

PURPOSE: CT-scan is increasingly used in blunt trauma, but the real impact on patient outcome is still unclear. This study was conducted to assess the effect of performing routine (versus selective) chest and abdominopelvic CT-scan on patient admission time and outcome in blunt trauma. METHODS: Conscious and hemodynamically stable high-energy trauma patients were included (n = 140). Routine chest and abdominopelvic CT-scan was requested in addition to the conventional radiography and ultrasound for the intervention group and selective CT-scan according to clinical presentation was done for the control group. Patient admission times in the emergency room and surgery ward, complications, and performed surgical procedures were assessed. "Unsuspected injuries" defined as additional findings on CT-scan, which were not expected before CT-scan, were evaluated. RESULTS: Admission time in the emergency ward and admission time in hospital were significantly shorter in the intervention group. Complications were similar in both groups. Abdominopelvic CT-scan in the intervention group revealed nine (7.8%) unsuspected injuries. All of these nine patients had also a positive clinical examination and injuries in other body regions. Chest CT-scan in the intervention group led to additional diagnoses in 17 patients (24.28%) leading to tube thoracostomy in 13 patients (18.57%). CONCLUSION: Routine chest and abdominopelvic CT-scan in conscious blunt trauma patients decreases the hospitalization time, but has no impact on patient outcome and probably might lead to overtreatment of occult injuries. The option of using a selective approach should be further evaluated to decrease radiation exposure and facility overuse.

Failure rate of prehospital chest decompression after severe thoracic trauma.

INTRODUCTION: Chest decompression can be performed by different techniques, like needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT). The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effectiveness of these techniques. MATERIAL AND METHODS: In this retrospective case series study, all medical records of adult trauma patients undergoing prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied. RESULTS: In a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen patients had NT, six patients TT, one patient NT as well as TT, and no patients had LT. Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT related complications were reported during hospitalization. CONCLUSION: Prehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission.

[What place for the thoracostomy-thoracmyoplasty in the management of the chronic pleural empyema?] / Quelle place pour la thoracostomie-thoracomyoplastie dans la prise en charge des pyothorax chronique ?

INTRODUCTION: The occurrence of empyema after pneumonectomy or in suites with chronic pleural pocket is a dreaded complication. The management is long and difficult. The authors report their experience before this complication including infection control by an emptying of the pleural pocket percutaneous drainage or thoracostomy which will be complemented by a thoracomyoplasty the aim to erase the pleural pocket. MATERIALS AND METHODS: This is a retrospective study conducted between 2009 and 2015 concerning the records of 9 patients treated for empyema or in the aftermath of a lung resection or as part of a chronic pleural pocket and calcific. RESULTS: We had identified all 9 male patients aged 30 to 67 years. This was pyothorax complicating pneumonectomy in 4 patients and 1 pyothorax after a left upper lobectomy in 1 case. For the other 4 patients, there was a post-tuberculous pleural pocket, calcified chronic and whose attempts to decortication seemed impossible. We observed 3 cases of bronchopleural fistula. All patients had received evacuation of the contents of the pleural drainage bag is either thoracostomy laying the bed of a possible filling thoracomyoplasty. The evolution of pleural cavities after thoracostomy was favorable on septic map leading to a retraction of the pleural cavity and its spontaneous closure in 1 patient. In 6 patients, filling the cavity with thoracomyoplasty was necessary. The evolution immediate postoperative was favorable in all patients and no deaths were noted in connection with this technique. CONCLUSION: Pyothorax on pneumonectomy cavity and chronic pleural calcified pockets are serious complications whose management is long and delicate. The thoracomyoplastie is a real alternative to the filling of the cavity in fragile patients with significant operational risk. The results are satisfactory in the hands of a broken team this technique.

Trends in treatment of infectious parapneumonic effusions in U.S. children's hospitals, 2004-2014.

PURPOSE: The purpose of this study was to examine trends in the treatment of patients with infectious parapneumonic effusions in U.S. children's hospitals over the past decade. METHODS: The PHIS database was queried for patients younger than 18years old with pneumonia and pleural effusion in three yearlong periods over the past decade. Variables included age, gender, payer, race/ethnicity, hospital region, hospital type, markers of illness severity, and treatment group (antibiotics alone, chest tube thoracostomy±thrombolytics, video-assisted thoracoscopy (VATS), or thoracotomy). RESULTS: 5569 patients were included in the final analysis. The proportion of patients treated with antibiotics alone increased from 62% to 74% from 2004 to 2014 (p<0.001). Among patients requiring pleural space drainage, the frequency of VATS peaked in 2009 (50.8%), dropping to 36.4% in 2014 (p<0.001), while tube thoracostomy, usually with fibrinolytics, rose from 39.0% in 2009 to 53.2% in 2014 (p<0.001). CONCLUSION: In a select cohort of free-standing, tertiary care U.S. children's hospitals, antibiotic administration alone remains the most common treatment approach to infectious parapneumonic effusions. VATS treatment for those patients requiring pleural space drainage is being gradually supplanted by thoracostomy tube placement with instillation of fibrinolytics.

Garrison Clinical Setting Inadequate for Maintenance of Procedural Skills for Emergency Medicine Physicians: A Cross-Sectional Study.

BACKGROUND: Emergency medicine physicians (EPs) are often placed in far-forward, isolated areas in theater. Maintenance of their emergency intervention skills is vital to keep the medical forces deployment ready. The US Army suggests that working at a Military Treatment Facility (MTF) is sufficient to keep emergency procedural skills at a deployment-ready level. We sought to compare the volume of emergency procedures that providers reported necessary to maintain their skills with the number available in the MTF setting. METHODS: EPs were surveyed to quantify the number of procedures they reported they would need to perform yearly to stay deployment-ready. We obtained procedure data for their duty stations and compared the procedure volume with the survey responses to determine if working at an MTF is sufficient to keep providers' skills deployment ready. RESULTS: The reported necessary average numbers per year were as follows: tube thoracostomy (5.9), intubation (11.4), cricothyrotomy (4.2), lumbar puncture (5.2), central line (10.0), focused assessment with sonography for trauma (FAST) (21.3), reductions (10.6), splints (10.5), and sedations (11.7). None of the procedure volumes at MTFs met provider requirements with the exception of FAST examinations at the only trauma center. CONCLUSIONS: This suggests the garrison clinical environment is inadequate for maintaining procedure skills. Further research is needed to determine modalities that will provide adequate training volume.

Traumatic chest injury in children: A single thoracic surgeon's experience in two Nigerian tertiary hospitals.

BACKGROUND: This study was to determine the extent and outcome of childhood chest injury in Nigeria, and to compare results with that of other literatures. PATIENTS AND METHODS: A Prospective study of all children under 18 years of age with chest trauma in two tertiary hospitals in Southern Nigeria from January 2012 to December 2014 was reviewed. The aetiology, type, associated injury, mechanism, treatment and outcome were evaluated. The patients were followed up in the clinic. The data were analysed using SPSS version 20.0 with a significant P < 0.05. RESULTS: Thirty-one patients (12.1%) under 18 years of age of 256 chest trauma patients were managed in the thoracic units. The mean age was 9.78 ± 6.77 years and 27 (87.1%) were male. The aetiology in 13 was from falls, 10 from automobile crashes, 3 from gunshots, 4 from stabbing and 1 from abuse. The highest peak of chest injury was on Saturday of the week and April of the year. The pleural collections are as follows: 15 (71.4%) was haemothorax, 4 (19.1%) pneumothorax, 2 (9.5%) haemopneumothorax and 18 patients had lung contusion in combination or alone with the pleural collections. Seven patients who presented >12-h versus 2 who presented <12-h and 6 of children between 0 and 9 years versus 3 at 10-18 years of age had empyema thoracis (P value not significant). One death was recorded. CONCLUSION: Chest trauma in children is still not common, and blunt chest injury from falls and automobile accidents are more common than penetrating chest injury. Treatment with tube thoracostomy is the major management modality with empyema thoracis as the most common complication.

Resuscitation During Critical Care Transportation in Afghanistan.

OBJECTIVE: These data describe the critical care procedures performed on, and the resuscitation markers of, critically wounded personnel in Afghanistan following point of injury (POI) transports and intratheater transports. Providing this information may help inform discussion on the design of critical care transportation platforms for future conflicts. METHODS: The Department of Defense Trauma Registry (DoDTR) was queried for descriptive data on combat casualties with Injury Severity Score (ISS) greater than 15 who were transported in Operation Enduring Freedom (OEF) from 1 January 2010 to 31 December 2010. Both POI transportation events and interfacility transportation events were reviewed. Base deficit (BD) was evaluated as a maker of resuscitation, and international normalized ratio (INR) was evaluated as a measure of coagulopathy. RESULTS: There were 1198 transportation events that occurred during the study period--634 (53%) transports from the POI and 564 (47%) intratheater transports. Critical care interventions were performed during 147 (12.3%) transportation events, including intubation, cricothyrotomy, double-lumen endotracheal tube placement, needle or tube thoracostomy, central venous access placement, and cardiopulmonary resuscitation. The mean BD on arrival in the emergency department was -5.4 mEq/L for POI transports and 0.68 mEq/L intratheater transports (ρ<.001). The mean INR on arrival in the emergency department was 1.48 for POI transports and 1.21 for intratheater transports (ρ<.001). CONCLUSIONS: Critical care interventions were needed frequently during evacuation of severely injured personnel. Furthermore, many troops arrived acidotic and coagulopathic following initial transport from POI. Together, these data suggest that a platform capable of damage control resuscitation and critical care interventions may be warranted on longer transports of more critically injured patients.