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1.
Emerg Med Pract ; 25(5, Suppl 1): 1-28, 2022 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-35467819

RESUMO

Pneumothorax, or air in the pleural space, is common in trauma, and has been found in up to 50% of severe polytrauma patients with chest injury. Findings associated with pneumothorax include dyspnea, chest pain, tachypnea, and absent breath sounds on lung auscultation. Although pneumothorax is traditionally diagnosed on plain film and confirmed with CT, the advent of portable ultrasonography has provided a way to rapidly diagnose pneumothorax, with a higher sensitivity than plain film. Patients with traumatic pneumothorax are typically treated with needle decompression or tube thoracostomy. However, recent literature has found that many patients can be managed conservatively via observation, or with a smaller thoracostomy such as a percutaneous pigtail catheter rather than a larger chest tube.


Assuntos
Pneumotórax , Traumatismos Torácicos , Tubos Torácicos , Serviço Hospitalar de Emergência , Humanos , Pneumotórax/cirurgia , Pneumotórax/terapia , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/terapia , Toracostomia
3.
Kyobu Geka ; 75(2): 155-159, 2022 Feb.
Artigo em Japonês | MEDLINE | ID: mdl-35249095

RESUMO

A 54-year-old male with alcoholic cirrhosis and diabetes mellitus was referred to our hospital for the treatment of right pleural empyema with fistula. Despite performing a simple suture closure of the pulmonary fistula, air leakage occurred one week after surgery. Hence, we covered the fistula with a pediculed muscle flap associated with an open window thoracostomy. After 32 days of gauze drainage, negative pressure wound therapy( NPWT) was introduced for reducing the residual pleural space. A chest computed tomography( CT) scan showed almost the full expansion of the lung after undergoing 98 days of NPWT. The patient was discharged from the hospital four months after thoracostomy.


Assuntos
Fístula Brônquica , Empiema Pleural , Empiema , Tratamento de Ferimentos com Pressão Negativa , Doenças Pleurais , Fístula Brônquica/complicações , Empiema/complicações , Empiema/cirurgia , Empiema Pleural/diagnóstico por imagem , Empiema Pleural/etiologia , Empiema Pleural/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Pleurais/complicações , Doenças Pleurais/cirurgia , Toracostomia
4.
Prehosp Disaster Med ; 37(1): 71-77, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35177133

RESUMO

BACKGROUND: New care paradigms are required to enable remote life-saving interventions (RLSIs) in extreme environments such as disaster settings. Informatics may assist through just-in-time expert remote-telementoring (RTM) or video-modelling (VM). Currently, RTM relies on real-time communication that may not be reliable in some locations, especially if communications fail. Neither technique has been extensively developed however, and both may be required to be performed by inexperienced providers to save lives. A pilot comparison was thus conducted. METHODS: Procedure-naïve Search-and-Rescue Technicians (SAR-Techs) performed a tube-thoracostomy (TT) on a surgical simulator, randomly allocated to RTM or VM. The VM group watched a pre-prepared video illustrating TT immediately prior, while the RTM group were remotely guided by an expert in real-time. Standard outcomes included success, safety, and tube-security for the TT procedure. RESULTS: There were no differences in experience between the groups. Of the 13 SAR-Techs randomized to VM, 12/13 (92%) placed the TT successfully, safely, and secured it properly, while 100% (11/11) of the TT placed by the RTM group were successful, safe, and secure. Statistically, there was no difference (P = 1.000) between RTM or VM in safety, success, or tube security. However, with VM, one subject cut himself, one did not puncture the pleura, and one had barely adequate placement. There were no such issues in the mentored group. Total time was significantly faster using RTM (P = .02). However, if time-to-watch was discounted, VM was quicker (P = .000). CONCLUSIONS: Random evaluation revealed both paradigms have attributes. If VM can be utilized during "travel-time," it is quicker but without facilitating "trouble shooting." On the other hand, RTM had no errors in TT placement and facilitated guidance and remediation by the mentor, presumably avoiding failure, increasing safety, and potentially providing psychological support. Ultimately, both techniques appear to have merit and may be complementary, justifying continued research into the human-factors of performing RLSIs in extreme environments that are likely needed in natural and man-made disasters.


Assuntos
Tubos Torácicos , Toracostomia , Humanos , Projetos Piloto , Toracostomia/métodos
5.
JAMA Surg ; 157(3): 269-274, 2022 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-35080596

RESUMO

IMPORTANCE: Thoracostomy, or chest tube placement, is used in a variety of clinical indications and can be lifesaving in certain circumstances. There have been developments and modifications to thoracostomy tubes, or chest tubes, over time, but they continue to be a staple in the thoracic surgeon's toolbox as well as adjacent specialties in medicine. This review will provide the nonexpert clinician a comprehensive understanding of the types of chest tubes, indications for their effective use, and key management details for ideal patient outcomes. OBSERVATIONS: This review describes the types of chest tubes, indications for use, techniques for placement, common anatomical landmarks that are encountered with placement and management, and an overview of complications that may arise with tube thoracostomy. In addition, the future direction of chest tubes is explored, as well as the management of chest tubes during the COVID-19 pandemic. CONCLUSIONS AND RELEVANCE: Chest tube management is subjective, but the compilation of data can inform best practices and safe application to successfully manage the pleural space and ameliorate acquired pleural space disease.


Assuntos
COVID-19 , Tubos Torácicos , Humanos , Pandemias , SARS-CoV-2 , Toracostomia/métodos
6.
J Trauma Acute Care Surg ; 92(1): 103-107, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34538823

RESUMO

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.


Assuntos
Procedimentos Clínicos , Sistemas de Apoio a Decisões Clínicas , Pneumotórax , Traumatismos Torácicos/complicações , Toracostomia , Tomografia Computadorizada por Raios X/métodos , Algoritmos , Tubos Torácicos , Regras de Decisão Clínica , Procedimentos Clínicos/normas , Procedimentos Clínicos/estatística & dados numéricos , Drenagem/instrumentação , Drenagem/métodos , Humanos , Monitorização Fisiológica/métodos , Pneumotórax/diagnóstico por imagem , Pneumotórax/etiologia , Pneumotórax/fisiopatologia , Pneumotórax/cirurgia , Radiografia Torácica/métodos , Risco Ajustado , Toracostomia/instrumentação , Toracostomia/métodos
7.
J Trauma Acute Care Surg ; 92(1): 177-184, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34538828

RESUMO

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.


Assuntos
Pneumotórax , Traumatismos Torácicos , Toracostomia , Tempo para o Tratamento/estatística & dados numéricos , Conduta Expectante , Ferimentos Penetrantes , Adulto , Duração da Terapia , Feminino , Humanos , Análise de Séries Temporais Interrompida/métodos , Análise de Séries Temporais Interrompida/estatística & dados numéricos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Pneumotórax/diagnóstico , Pneumotórax/etiologia , Pneumotórax/terapia , Prognóstico , Radiografia Torácica/métodos , Reoperação/métodos , Reoperação/estatística & dados numéricos , Medição de Risco , Toracentese/efeitos adversos , Toracentese/métodos , Traumatismos Torácicos/complicações , Traumatismos Torácicos/epidemiologia , Toracostomia/efeitos adversos , Toracostomia/métodos , Toracostomia/estatística & dados numéricos , Estados Unidos/epidemiologia , Conduta Expectante/métodos , Conduta Expectante/estatística & dados numéricos , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia
8.
J Surg Res ; 269: 51-58, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34520982

RESUMO

BACKGROUND: Use of routine chest x-rays (CXR) following thoracostomy tube (TT) removal is highly variable and its utility is debated. We hypothesize that routine post-pull chest x-ray (PP-CXR) findings following TT removal in pediatric trauma would not guide the decision for TT reinsertion. METHODS: Patients ≤ 18 y who were not mechanically ventilated and undergoing final TT removal for a traumatic hemothorax (HTX) and/or pneumothorax (PTX) at a level I pediatric trauma center from 2010 to 2020 were retrospectively reviewed. The outcomes of interest were rate of PP-CXR and TT reinsertion rate following PP-CXR. Clinical predictors for worsened findings on PP-CXR were also assessed. RESULTS: Fifty-nine patients were included. A CXR after TT removal was performed in 57 patients (97%), with 28% demonstrating worsened CXR findings compared to the prior film. Except for higher ISS (p = 0.033), there were no demographic or clinical predictors for worsened CXR findings. However, they were more likely to have additional films following the TT removal (p = 0.008) than those with stable or improved PP-CXR findings. One (1.8%) asymptomatic child with worsened PP-CXR findings had TT reinsertion based purely on their worsened PP-CXR findings. CONCLUSIONS: The vast majority of PP-CXR did not guide TT reinsertion after pediatric thoracic trauma. Treatment algorithms may aid to reduce variability and potentially unnecessary routine films.


Assuntos
Pneumotórax , Traumatismos Torácicos , Tubos Torácicos/efeitos adversos , Criança , Humanos , Pneumotórax/etiologia , Pneumotórax/cirurgia , Estudos Retrospectivos , Traumatismos Torácicos/cirurgia , Toracostomia/efeitos adversos
9.
J Vet Emerg Crit Care (San Antonio) ; 32(1): 58-67, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34499801

RESUMO

OBJECTIVE: To report the rate of fluid production at the time of removal of thoracostomy tubes placed intraoperatively and to determine the association of this rate with specific patient factors, surgical factors, or clinical diagnosis. The secondary objective was to determine whether identification of pleural effusion within 2 weeks of thoracostomy tube removal was associated with the same variables. DESIGN: Retrospective study. SETTING: University teaching hospital. ANIMALS: One hundred eighty-five client-owned dogs with thoracostomy tubes placed intraoperatively between January 2010 and March 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thoracostomy tubes were removed at a median fluid production of 0.09 mL/kg/h (range, 0-7.0 m L/kg/h). Median fluid production at the time of thoracostomy tube removal was significantly higher in dogs with preoperative pleural effusion compared to dogs without preoperative pleural effusion (0.21 vs 0.05 mL/kg/h; P = 0.0001) and in dogs that had a median sternotomy compared to dogs that had a lateral thoracotomy (0.14 vs 0.09 mL/kg/h; P = 0.04). Of the 169 dogs available for follow-up, 12 (7.1%) had pleural effusion within 2 weeks of removal of the thoracostomy tube. Detection of pleural effusion during the follow-up period was significantly associated with the presence of preoperative pleural effusion (P = 0.0019) and the diagnosis (P = 0.01). A greater proportion of dogs with a lung lobe torsion (4/9, 44.4%) and idiopathic chylothorax (2/7, 28.5%) had pleural effusion within 2 weeks compared to other diagnoses. Reintervention was performed in 4.7% of dogs. CONCLUSIONS: Thoracostomy tubes were removed at pleural fluid production rates that frequently exceeded current veterinary guidelines. However, the fluid production rate at the time of thoracostomy tube removal was not associated with the detection of pleural effusion within 2 weeks of thoracostomy tube removal, and the overall need for reintervention following thoracostomy tube removal was low (4.7%).


Assuntos
Doenças do Cão , Derrame Pleural , Animais , Tubos Torácicos , Doenças do Cão/cirurgia , Cães , Derrame Pleural/cirurgia , Derrame Pleural/veterinária , Estudos Retrospectivos , Toracostomia/veterinária , Toracotomia/veterinária
10.
Neonatology ; 119(1): 33-40, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-34844248

RESUMO

BACKGROUND: Inserting a chest drain for a left-sided neonatal pneumothorax carries a risk of penetrating the pericardium. We identified reference ranges for the chest wall thickness (CWT) and distance between the pericardium and parietal pleura to improve safety of chest tube insertion. METHOD: We prospectively measured the CWT using ultrasound in 20 neonates (body weight [BW] 640-2,700 g, age <10 days) at the usual site of puncture in the 4th and 5th intercostal space (ICS). Furthermore, we measured the minimal distance between the parietal pleura and the cardiac silhouette in 131 neonatal chest X-rays (birth weight, 420-4,930 g [divided into 11 weight groups]; age <10 days). Both data sets were transformed into weight-dependent percentiles (Ps). We considered the difference between the sum of P 2.5 for the CWT plus P 2.5 for pleura-heart distance minus P 97.5 for the CWT as a safe corridor for placing the tip of the needle. RESULTS: At both ICSs, curves for the above metrics did not cross, indicating a narrow but safe corridor for each BW with at least 97.5% probability. This safety corridor was 4.6-5.2 mm wide for the 4th and 2.8-3.4 mm for the 5th ICS. CONCLUSION: These data offer a reference for left-sided chest drain insertion for BW <2,700 g, which may help to improve safety of the procedure.


Assuntos
Pneumotórax , Parede Torácica , Tubos Torácicos , Humanos , Recém-Nascido , Agulhas , Pneumotórax/diagnóstico por imagem , Pneumotórax/etiologia , Toracostomia/métodos
11.
Gynecol Oncol ; 164(2): 271-277, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34844774

RESUMO

INTRODUCTION: Ovarian cancer (OC) represent nearly 4% of gynecologic malignancies and it is often diagnosed at advanced stage. Diaphragmatic surgery, a fundamental step of advanced stage ovarian cancer (ASOC) debulking surgery, is associated with a high post-operative complication incidence, which is supposedly reduced with thoracostomy tube placement. We assessed the role of intra-operative thoracostomy tube placement, as a prevention measure for post-operative complications, after diaphragmatic resection. METHODS: This was a single center prospective randomized trial. Ovarian cancer patients, who underwent mono-lateral diaphragmatic resection, were randomized 1:1 into two arms. Arm A included patients receiving intra-operative thoracostomy tube placement (TP); Arm B patients did not receive thoracostomy tube placement (NTP). After surgery, all patients underwent seriate chest x-ray and ultrasound to record thoracic complications. Statistical analysis included uni- and multivariable logistic regression model (proportional odds model). RESULTS: Three hundred seventy-one patients were screened and 88 patients were enrolled: 44 in arm A and B, respectively. No statistically significant differences for intra-operative (p = 0.291) and any grade of post-operative complication (p = 0.072) were detected, while 6.8% of patients in arm A and 22.7% in arm B experienced severe respiratory symptoms (p = 0.035); 18.2% of patients in arm A had a moderate/large pleural effusion versus 65.9% in arm B (p < 0.0001). At multivariable analysis, results confirmed that the NTP-group had a higher risk to receive post-operative thoracostomy tube placement due to pleural effusion than the TP-group (odds ratio [95% Confidence Interval] = 14.5 [3.7-57.4]). CONCLUSIONS: Thoracostomy intra-operative tube placement after diaphragmatic resection is effective to prevent post-operative thoracic complications. The extension of resection does not influence outcomes and the risk of post-operative thoracentesis or TP remain elevated.


Assuntos
Carcinoma Epitelial do Ovário/cirurgia , Tubos Torácicos , Procedimentos Cirúrgicos de Citorredução/métodos , Diafragma/cirurgia , Cuidados Intraoperatórios/métodos , Neoplasias Ovarianas/cirurgia , Derrame Pleural/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Toracostomia/métodos , Adulto , Idoso , Carcinoma Epitelial do Ovário/patologia , Feminino , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Neoplasias Ovarianas/patologia
12.
J Ultrasound Med ; 41(3): 743-747, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34086998

RESUMO

OBJECTIVES: Thoracostomy is often a required treatment in patients with thoracic trauma; however, performing a thoracostomy using traditional techniques can have complications. Ultrasound can be a beneficial tool for identifying the correct thoracostomy insertion site. We designed a randomized prospective study to assess if ultrasound guidance can improve thoracostomy site identification over traditional techniques. METHODS: Emergency medicine residents were randomly assigned to use palpation or ultrasound to identify a safe insertion site for thoracostomy placement. The target population comprised of hemodynamically stable trauma patients who received an extended focused assessment with sonography for trauma (EFAST) and a chest computed tomography (CT) exam. The resident placed a radiopaque marker on the skin of the patient where a safe intercostal space was believed to be located, either by palpation or ultrasound. Clinical ultrasound faculty reviewed the CT to confirm marker placement relative to the diaphragm. A Fischer's exact test was used to analyze the groups. RESULTS: One hundred and forty-seven patients were enrolled in the study, 75 in the ultrasound group and 72 in the landmark group. This resulted in the placement of 271 total thoracostomy site markers, 142 by ultrasound and 129 by palpation and landmarks. The ultrasound group correctly identified thoracostomy insertion sites above the diaphragm in 97.2% (138/142) of patients, while the palpation group identified a safe insertion site in 88.4% (114/129) of patients (P = .0073). CONCLUSION: This study found that emergency medicine residents are more likely to identify a safe tube thoracostomy insertion site in trauma patients by using ultrasound, as compared to using landmarks and palpation.


Assuntos
Pneumotórax , Traumatismos Torácicos , Tubos Torácicos , Humanos , Estudos Prospectivos , Toracostomia , Ultrassonografia de Intervenção
13.
Eur J Trauma Emerg Surg ; 48(2): 1513-1518, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33796890

RESUMO

INTRODUCTION: Occult pneumothorax (OPTX) is defined as air in the pleural space that was not suspected on plain chest X-ray but detected on CT. Controversy exists in the management of OPTX, especially in patients who require positive pressure ventilation (PPV). In this study, we investigated the need for tube thoracostomy (TT) in blunt trauma patients with OPTX. MATERIALS AND METHODS: This is a retrospective study of blunt trauma patients of all ages with evidence of OPTX, treated in the Shamir Medical Center Trauma Unit between 2008 and 2017. Two groups were defined. Group I consisted of patients requiring PPV. Group II included patients who did not require PPV. We identified the indication for TT insertion (hemothorax, significant pneumothorax, and enlarging pneumothorax). Necessity for delayed TT insertion due to enlarging pneumothorax was analyzed. RESULTS: Overall 512 patients with traumatic pneumothorax were admitted. 197 (38.5%) had OPTX. Motor vehicle accidents and falls from height accounted for most of the injuries, 47.2 and 42.6%, respectively. Fifty-seven patients required PPV. TT was required in 31 (15.7%) patients. No differences were found between the overall rate of TT insertion between the groups (15.7 vs. 21.1%; p = 0.2) and for delayed insertion of a TT due to an enlarging pneumothorax (25.0 vs. 42.1%; p = 0.45). CONCLUSION: TT is not indicated in every patient with OPTX even in case of mechanical ventilation.


Assuntos
Pneumotórax , Traumatismos Torácicos , Ferimentos não Penetrantes , Tubos Torácicos , Humanos , Pneumotórax/diagnóstico por imagem , Pneumotórax/cirurgia , Estudos Retrospectivos , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/cirurgia , Toracostomia/métodos , Tempo para o Tratamento , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgia
14.
Chest ; 161(1): 276-283, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34390708

RESUMO

Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.


Assuntos
Hidrotórax/terapia , Hipertensão Portal/complicações , Cirrose Hepática/complicações , Derrame Pleural/terapia , Pleurodese , Toracentese , Toracostomia , Cateteres de Demora , Tubos Torácicos , Gerenciamento Clínico , Humanos , Hidrotórax/etiologia , Hepatopatias/complicações , Cavidade Pleural , Derrame Pleural/etiologia
15.
Gen Thorac Cardiovasc Surg ; 70(1): 59-63, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34296395

RESUMO

Tension pneumothorax is a life-threatening condition that can develop when either the visceral pleura is disrupted, or with injury to the tracheobronchial tree. Rapid, accurate diagnosis and appropriate management are required to prevent significant atelectasis, hypoxia, circulatory arrest, and ultimate patient demise. Needle decompression is the current standard of care for the management of tension pneumothorax. Healthcare providers struggle to assess the success of decompression due to a lack of any immediate objective feedback. The gaseous composition of tension pneumothorax is similar to that of end respiratory gas. This includes an increased partial pressure of carbon dioxide in comparison to atmospheric air, which makes colorimetric capnography an ideal confirmatory test. This colorimetric capnography device may help the healthcare providers to make an objective and accurate assessment of the success of the needle decompression, in particular in prehospital environments.


Assuntos
Pneumotórax , Capnografia , Colorimetria , Descompressão Cirúrgica , Humanos , Pneumotórax/diagnóstico , Pneumotórax/cirurgia , Toracostomia
16.
Eur J Trauma Emerg Surg ; 48(2): 973-979, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33244615

RESUMO

PURPOSE: Tube thoracostomy (TT) is a simple and a life-saving procedure; nevertheless, it carries morbidity, even after its removal. Currently, TT is managed and removed by chest X-ray (CXR) evaluation. There are limitations and these are directly linked to complications. The use of thoracic ultrasound (US) has already been established in the diagnosis of pneumothorax (PTX) and hemothorax (HTX); its use, in substitution of CXR can lead to improvement in care. Our aim is to evaluate the efficiency and safety of US in the management of TT. METHODS: Prospective and randomized study with patients requiring TT. They were divided in groups according to their thoracic injuries (PTX and HTX) and randomized into two groups according to TT management: US and CXR. Data collected included gender, age, mechanism of injury, days to TT removal, complications after TT removal and presence of mechanical ventilation. RESULTS: Sixty-one patients were randomized, of which 68.8% were male. The most frequent diagnosis was PTX, present in 37 cases. Median time for TT removal was 2.5 days in the US group and 4.9 in the control group (p = 0.009). The complication rate was 6.6%, with no morbidity in the US group. TT removal in patients with mechanical ventilation did not increase the incidence of complications. CONCLUSIONS: The use of US in the management is efficient and safe. It allows early TT removal regardless the cause of the thoracic injury.


Assuntos
Pneumotórax , Traumatismos Torácicos , Tubos Torácicos/efeitos adversos , Hemotórax/diagnóstico por imagem , Hemotórax/etiologia , Hemotórax/cirurgia , Humanos , Masculino , Projetos Piloto , Pneumotórax/diagnóstico por imagem , Pneumotórax/etiologia , Estudos Prospectivos , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/cirurgia , Toracostomia/métodos
17.
J Trauma Acute Care Surg ; 92(1): 44-48, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34932040

RESUMO

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.


Assuntos
Pneumotórax , Traumatismos Torácicos , Toracostomia , Tomografia Computadorizada por Raios X , Ultrassonografia , Erros de Diagnóstico/prevenção & controle , Erros de Diagnóstico/estatística & dados numéricos , Reações Falso-Negativas , Feminino , Humanos , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Posicionamento do Paciente/métodos , Pneumotórax/diagnóstico por imagem , Pneumotórax/etiologia , Radiografia Torácica/métodos , Radiografia Torácica/normas , Sensibilidade e Especificidade , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/epidemiologia , Toracostomia/instrumentação , Toracostomia/métodos , Toracostomia/estatística & dados numéricos , Tempo para o Tratamento , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/normas , Centros de Traumatologia/estatística & dados numéricos , Ultrassonografia/métodos , Ultrassonografia/normas , Estados Unidos/epidemiologia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/epidemiologia
18.
Anaesthesiol Intensive Ther ; 53(5): 456-465, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34870385

RESUMO

Thoracostomy requires interdisciplinary teamwork. Even though thoracic drainage is a technical surgical procedure, nurses play an important role with major responsibilities during the procedure. This literature review aimed to identify articles related to the interdisciplinary management of thoracostomy. An integrative literature analysis between 2012 and 2019 with a qualitative approach was conducted. An analysis of articles written in English, French, Portuguese, and Spanish was conducted. A search of the PubMed and SCIELO databases was performed using combinations of the terms "Chest Tube; Nursing; Care; Drainage; Insertion". The search terms were included in 11,277 articles. After excluding articles that did not meet the objective of our study, 475 abstracts were analysed. Finally, 19 articles were selected with content focused on nursing care, content related to surgical procedures, and interdisciplinary content. Themes included the following: description of the procedure, interdisciplinary action, quality of the procedure, use of protocols for patient safety, and new technologies. In conclusion, interdisciplinary courses should be encouraged to improve interprofessional teamwork organization. Notwithstanding all these publications, the literature was fragmented into disciplines and isolated analyses. Each medical or nursing discipline addressed the aspects that pertain to its own responsibilities in the execution of the procedure. This review highlighted the need to develop interdisciplinary research and brought a source of rich information that can instrumentalize the creation of optimized processes for the interdisciplinary chest tube insertion.


Assuntos
Tubos Torácicos , Toracostomia , Drenagem , Humanos , Toracostomia/métodos
19.
Scand J Trauma Resusc Emerg Med ; 29(1): 166, 2021 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-34863280

RESUMO

BACKGROUND: Open thoracostomies have become the standard of care in pre-hospital critical care in patients with chest injuries receiving positive pressure ventilation. The procedure has embedded itself as a rapid method to decompress air or fluid in the chest cavity since its original description in 1995, with a complication rate equal to or better than the out-of-hospital insertion of indwelling pleural catheters. A literature review was performed to explore potential negative implications of open thoracostomies and discuss its role in mechanically ventilated patients without clinical features of pneumothorax. MAIN FINDINGS: A rapid review of key healthcare databases showed a significant rate of complications associated with pre-hospital open thoracostomies. Of 352 thoracostomies included in the final analysis, 10.6% (n = 38) led to complications of which most were related to operator error or infection (n = 26). Pneumothoraces were missed in 2.2% (n = 8) of all cases. CONCLUSION: There is an appreciable complication rate associated with pre-hospital open thoracostomy. Based on a risk/benefit decision for individual patients, it may be appropriate to withhold intervention in the absence of clinical features, but consideration must be given to the environment where the patient will be monitored during care and transfer. Chest ultrasound can be an effective assessment adjunct to rule in pneumothorax, and may have a role in mitigating the rate of missed cases.


Assuntos
Pneumotórax , Traumatismos Torácicos , Tubos Torácicos , Hospitais , Humanos , Pneumotórax/etiologia , Toracostomia
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