ETM Journal Club: A procedural check list for pleural decompression and intercostal catheter insertion for adult major trauma.

Injury, Int. J. Care Injured 46 (2015) 42–44  (As of Feb 28th 2015 – available full-text free)

The goal of treatment for traumatic pneumothoraces is pleural decompression, not placement of a tube. Correct insertion technique for intercostal catheters after chest decompression is however essential to avoid the many potential complications of this procedure.

Complications of tube thoracostomy include:

  • Extra thoracic placement – subcutaneous, sub diaphragmatic
  • Malposition – too shallow (not all drainage holes in pleural cavity), in fissure of lung
  • Mulitple pleural punctures (from losing the insertion tract) – can lead to massive (even whole-body) subcutaneous emphysema
  • Solid organ injury: heart/mediastinum, lung, liver spleen
  • Bleeding: From skin, incised (rather than blunt dissected) muscle, lateral thoracic artery, and intercostal artery or vein
  • Infection – cutaneous or empyema

In this article, from a high-volume, level-1 Australian trauma centre, the use of a checklist, aimed at minimising empyema rates is studied. At face value the empyema rate drops after implementation of the checklist. However there are many limitations to this study, which are acknowledged by the authors. These include:

  • The checklist was introduced alongside a formal teaching program, so the contribution of either element cannot be deduced.
  • It’s not clear if every patient who underwent tube thoracostomy had it inserted by someone who had undergone the training program, or if they actually had the checklist used in their case.
  • There was no randomisation or blinding.
  • The “baseline” empyema rate was already very low, and fluctuating (from just over 1% to 3.5%), and the pre-implementation rate was calculated over 6.5 years. The post implementation rate was only measured over 2 years. Had the study period been extended the average empyema rate over time may have dropped, and the subsequent difference been less.
  • Other factors such as: routine administration of IV antibiotics on insertion, improved senior medical staff supervision and improvements in the overall management of trauma patients (although these are not listed) may also have contributed

Summary:

When studying a low incidence problem, it’s very hard to measure a direct effect of an intervention without much more rigorous study design.

Unfortunately this paper cannot be used as evidence of benefit of checklist use during ICC insertion.

It is still useful in that it demonstrates one method of attempting to standardise the performance of a procedure that is not benign, and that the combination of standardised education and procedure training, protocols, close supervision and use of aids like checklists may minimise complications for high risk ED procedures.

Checklist use is becoming more common in Emergency Departments in Australia, particularly for airway management and rapid sequence intubation. Evidence for benefit of checklist use in this setting is scant to non-existent, however anecdotally practitioners who use them report many benefits, including improved team communication, better anticipation and preparation for complications/failure and decreased likelihood of forgetting critical procedural elements. In our highly distraction-prone environment, checklist use for other invasive procedures in the ED may be useful, if only to attempt to standardise their performance with the aim of minimising complications.

Bonus:
If you want to read a great article on how to perform tube thoracostomy, there’s a recent (and currently free) article by Ben Butson and Paul Kwa from Townsville in the January 2015 Emergency Medicine Australasia.

What do you think of checklist use for invasive ED procedures? Leave a comment below.

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