Category: Thoracic 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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The last year or two have seen some excellent online discussion and teaching around the enigmatic procedure of ED thoracotomy, including Scott Weingart from EMCrit’s “Crack to Cure” talk (also given at SMACC recently), and Cliff Reid at Resus.me has done some posts on traumatic arrest and thoracotomy as well (here and here).

In the latest Journal of Trauma there’s an interesting article that looks at post discharge functional outcomes from a group of ED thoracotomy survivors.  Despite the small sample size, some interesting points are noted, including an impressive 8.3% survival to discharge rate (nearly all were penetrating trauma), the vast majority of which had a reasonable functional status at long term followup. Two-thirds were discharged home, and only 6% were discharged to nursing homes.

75% of survivors had normal cognition, had returned to “normal activities”,  and had no evidence of post-traumatic stress disorder, and over 80% were freely mobile and functional. The authors note a high incidence of unemployment and drug/alcohol use, however this was not covered in the discussion, so pre-morbid factors may be at play with these results.  The discussion section is worth a read as a summary of outcomes for different types of traumatic injury, as these have been studied in detail in other referenced papers.  Importantly they note a comment from a study of survivors of traumatic brain injury, that sometimes resuscitation and ICU care leading to survival sentences the patient to “a fate worse than death” (ie long term severe impairment and nursing home care).  No clear predictors of who will do well after ED thoractotomy can be gleaned from this study, but younger age appeared to be the main factor associated with better outcome.

So what’s the take home message?
The chance of survival of an ED thoracotomy is low, and you need to know the right patients to try it on, however if the patient survives the procedure, they have a high chance of regaining some semblance of normal function should they make it to hospital discharge. The younger the (adult) patient, the higher the chances of a good outcome.

As Cliff mentioned in his post about Kenji Inaba’s study, even if they don’t survive, the potential for organ donation should also be kept in mind.

Reference:

Keller D, Kulp H, Maher Z, Santora TA, Goldberg AJ, Seamon MJ. Life after near death: Long-term outcomes of emergency department thoracotomy survivors J Trauma Acute Care Surg. 2013 May;74(5):1315-20

 

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