American Journal of Emergency Medicine 33 (2015) 88–91
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Chest tube insertion direction: is it always necessary to insert a chest tube posteriorly in primary trauma care?☆ Shokei Matsumoto, MD a,⁎, Kazuhiko Sekine, MD b, Tomohiro Funabiki, MD a, Motoyasu Yamazaki, MD a, Tomohiko Orita, MD a, Masayuki Shimizu, MD a, Kei Hayashida, MD a, Masanobu Kishikawa, MD c, Mitsuhide Kitano, MD a a b c
Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan Department of Emergency Medicine, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan Division of Emergency Medicine, Fukuoka City Hospital, Hakata-ku, Fukuoka-shi, Fukuoka, Japan
a r t i c l e
i n f o
Article history: Received 10 October 2014 Received in revised form 21 October 2014 Accepted 23 October 2014
a b s t r a c t Background: The advanced trauma life support guidelines suggest that, in primary care, the chest tube should be placed posteriorly along the inside of the chest wall. A chest tube located in the posterior pleural cavity is of use in monitoring the volume of hemothoraces. However, posterior chest tubes have a tendency to act as nonfunctional drains for the evacuation of pneumothoraces, and additional chest tube may be required. Thus, it is not always necessary to insert chest tubes posteriorly. The purpose of this study was to determine whether posterior chest tubes are unnecessary in trauma care. Methods: We reviewed the volume of hemothoraces from 78 chest drains emergently placed posteriorly at a primary trauma care in 75 blunt chest trauma patients who were consecutively admitted over a 6-year period, excluding those with cardiopulmonary arrest and occult pneumothoraces. Massive acute hemothorax (MAH), in which the chest tube should be inserted posteriorly, was defined as the evacuation of more than 500 mL of blood or the need for hemostatic intervention within 24 hours of trauma admission. Demographics, interventions, and outcomes were analyzed. We also reviewed the malpositioning of 74 chest tubes based on anterior and posterior insertion directions in patients who subsequently underwent computed tomography. Results: The overall incidence of MAH was 23% (n = 18). In the univariate analysis, the presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation were found to be independent predictors for the development of MAH. If all 4 independent predictors were absent, none of the patients developed MAH. The incidence of nonfunctional chest drains that required reinsertion or the addition of a new drainage was 27% (n = 20). The rates of both radiologic and functional malposition in chest tubes with posterior insertion were significantly higher than in patients with anterior insertion (64% and 43% vs 13% and 6%, respectively; P b .01). Conclusions: Chest tubes did not need to be directed posteriorly in many trauma cases. Posterior chest tubes have a high incidence of being malpositioned. This malpositioning may be prevented by judging the necessity for posterior insertion. © 2014 Elsevier Inc. All rights reserved.
1. Background Traumatic pneumothoraces and hemothoraces are major thoracic injuries that can be commonly treated with the insertion of a chest tube [1]. Unfortunately, it has been noted that malpositioned chest ☆ None of the authors have any conflicts of interest regarding any of the materials used in this study. ⁎ Corresponding author at: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012, Japan. Tel.: +81 45 576 3000; fax: +81 45 576 3586. E-mail addresses: [email protected] (S. Matsumoto), [email protected] (K. Sekine), [email protected] (T. Funabiki), [email protected] (M. Yamazaki), [email protected] (T. Orita), [email protected] (M. Shimizu), [email protected] (K. Hayashida), [email protected] (M. Kishikawa), [email protected] (M. Kitano). http://dx.doi.org/10.1016/j.ajem.2014.10.042 0735-6757/© 2014 Elsevier Inc. All rights reserved.
tubes and related complications occur at a high rate (22%-53%) [2-6]. The advanced trauma life support (ATLS) guidelines suggest that, in primary trauma care, the chest tube should be placed “posteriorly” along the inside of the chest wall because a chest tube located in the posterior pleural cavity is useful in monitoring the volume of hemothoraces [7]. Theoretically, chest tubes that are placed in the posterior pleural cavity have a tendency to act as nonfunctional drains for the evacuation of pneumothoraces, and chest tube reinsertion or addition may be required (Fig. 1). Naturally, a posteriorly inserted chest tube becomes a necessity in cases of hemothorax. There are, however, many cases of pneumothorax in which hemothorax is absent. Thus, we hypothesized that it is not always necessary to insert chest tubes posteriorly for traumatic pneumothoraces. The purpose of this study was to evaluate whether a posterior chest tube insertion was necessary in primary trauma care. This primary end point was
S. Matsumoto et al. / American Journal of Emergency Medicine 33 (2015) 88–91
89
A
B
Fig. 1. Computed radiography shows a nonfunctional chest tube inserted to evacuate pneumothoraces. The chest tube was directed posteriorly along the inside of the chest wall (arrowhead), and reinsertion of the tube proved necessary. Meanwhile, only 50 mL of blood was obtained through the chest tube 24 hours after admission.
designed to identify the incidence and corresponding risk factors for traumatic pneumothoraces in the presence of a hemothorax, which should be monitored. This secondary end point was designed to identify the incidence of malpositioned chest tubes based on different insertion directions using computed tomography (CT). 2. Methods 2.1. Patients and clinical management This noninterventional, observational study was conducted in the Emergency and Trauma Centre, a tertiary-care hospital in Japan from January 1, 2008, to December 31, 2013. Consecutive adult blunt trauma patients, who were diagnosed with traumatic pneumothoraces at a primary trauma survey using a chest x-ray, were prospectively enrolled. Patients who had cardiopulmonary arrest, hemothoraces without pneumothorax, and/or occult pneumothorax were excluded. In accordance with ATLS guidelines, all patients were examined and underwent a chest x-ray immediately upon admission. The presence of a pneumothorax was determined from the chest x-ray, and chest tubes were routinely inserted by a resident physician. Chest tubes ranging in size from 22F to 32F were directed posteriorly along the inside of the chest wall at the middle axillary lines (posterior insertion) or anteriorly along the inside of the chest wall at the anterior axillary lines (anterior insertion) using a blunt dissection technique (Fig. 2). The chest tube was managed with a water seal drainage system without suction (Chest Drainage Vac; Sumitomo Bakelite Co, Tokyo, Japan). The direction of tube insertion (posterior or anterior) was determined on a case-by-case basis after a review of the images and the clinical findings in primary trauma care. After chest tube insertion and resuscitation, CT scans were performed with 64 multidetector CT scanners (Aquilion CT scanner; Toshiba, Tokyo, Japan). 2.2. Data collection and definitions We collected the following data: demographics, injury severity score (ISS), the presence of rib fractures, shock, pulmonary opacities on chest x-ray, volume of hemothorax via chest tube, the need for intubation, hemostatic procedure, and outcomes. The necessity of posterior insertion for monitoring hemothorax was measured by the presence of massive acute hemothorax (MAH). Massive acute hemothorax was defined as the evacuation of more than 500 mL of blood, the need for the emergency hemostatic procedure, or adding another chest tube for hemothorax within 24 hours of trauma admission. The presence of
Fig. 2. The direction for inserting a chest tube using a blunt dissection technique. A, Anterior insertion, a chest tube is directed anteriorly along the inside of the chest wall at the anterior axillary lines. B, Posterior insertion, a chest tube is directed posteriorly along the inside of the chest wall at the middle axillary lines.
radiologic malposition and residual pneumothorax on CT scans was reported by an experienced faculty radiologist (TF). Malposition on CT was classified according to the previous report by Huber-Wagner et al [3] as extrathoracic, abdominal, parenchymal, or interlobal. Residual pneumothorax was defined as a thickness of 10 mm or more for the largest air collection along a line perpendicular from the chest wall to the lung. Furthermore, functional malposition was defined as a residual pneumothorax requiring clinical repositioning or the addition of a chest tube by the attending physician. 2.3. Statistical analysis The primary end point of the present portion of our study was the identification of the risk factors for the development of MAH for patients with traumatic pneumothorax. The secondary end point was the identification of the incidence of malpositioning (radiologic and functional) related to different chest tube insertion directions. We compared the demographic and clinical characteristics between patients who developed MAH and those who did not. For the univariate analysis, we used the χ 2 test with Yates correction for comparison of categorical risk factors and the Student t test for comparison of continuous risk factors. Relative risks (RRs) were calculated with the corresponding 95% confidence intervals (CIs). P b .050 was considered statistically significant. All statistical analyses were performed using SPSS for Windows version 15.0 (IBM, Armonk, NY). 3. Results During this study, a total of 4542 patients entered the emergency department (ED) as trauma victims, and 190 patients were diagnosed with traumatic pneumothorax. From this subset, 115 patients were excluded (17 patients who had cardiopulmonary arrest and 98 who had occult pneumothorax). The remaining 75 patients, with 3 of these patients having bilateral pneumothoraces, met our study criteria. All these enrolled patients received chest tubes in the ED. The 7 residents (4 in emergency medicine and 3 in general surgery) who performed the chest tube insertions had trained for an average of 3 years. 3.1. Predictors of massive acute hemothorax in the ED Table 1 summarizes the patient characteristics and outcomes of the study on MAH. The overall incidence of MAH was 23% (n = 18).
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Table 1 Comparison of characteristics and outcome in chest tubes with MAH or without MAH
Age, y Male, n (%) Right side, n (%) Pulmonary opacities on chest x-ray GCS ISS Rib fracture Multiple rib fractures Shock Positive pressure ventilation Hemostatic intervention Mortality, n (%)
MAH
Non-MAH
n = 18 (23%)
n = 60 (77%)
52.1 ± 17.6 16 (89%) 10 (56%) 11 (61%) 11.5 ± 4.2 32.4 ± 11.0 17 (94%) 16 (88%) 12 (67%) 15 (83%) 9 (50%) 4 (22%)
43.6 ± 17.2 50 (83%) 33 (55%) 3 (5%) 12.7 ± 3.6 26.8 ± 14.1 48 (80%) 30 (50%) 15 (25%) 22 (37%) 0 1 (2%)
P
.847 .722 .788 b.001 .245 .238 .278 .005 .002 .001 b.001 .009
Massive acute hemothorax was defined as more than 500 mL or the need for emergency thoracotomy for hemostasis or adding another chest tube for hemothorax within 24 hours of trauma admission. Values are expressed as mean ± SD or n (%).
Nine patients (50%) with MAH required an immediate hemostatic intervention in the form of exploratory thoracotomy (6 patients) or angioembolization (three patients). No patient without MAH required an immediate intervention. At the primary trauma care, the presence of multiple rib fractures (RR, 8.00; 95% CI, 1.69-37.87), shock (RR, 6.00; 95% CI, 1.92-18.78), pulmonary opacities on chest x-ray (RR, 29.86; 95% CI, 6.67-133.6), and the need for intubation (RR, 8.64; 95% CI, 2.25-33.12) were found to be independent predictors for the development of MAH. If all 4 independent predictors were absent, none of the patients developed MAH. In contrast, if all 4 independent predictors were present, all patients developed MAH, and 71% of the patients (5/7) required hemostatic intervention. 3.2. Malposition of chest tube from different directions (posterior or anterior) Overall, 4 patients could not be evaluated for malpositioning using a CT scan because 3 patients were managed with a chest tube insertion after the CT was performed and 1 patient was in a state of severe shock. Therefore, the remaining 71 patients, including the 3 patients with bilateral pneumothoraces, were included for evaluation of malpositioning. Of the 74 chest tubes inserted, 32 (46%) were inserted anteriorly, and 42 (60%) were inserted posteriorly. There were statistically significant differences in the severity between the 2 groups. Posterior insertion was chosen in patients who had a lower Glasgow Coma Scale (14 ± 3 vs 11 ± 4; P = .008), a higher incidence of shock (9% vs 55%; P b .001), and a higher ISS (22 ± 11 vs 34 ± 13; P b .001) compared with patients for whom anterior insertion was chosen. There was no difference in the sex, age, or mortality between the 2 groups. Table 2 shows the incidence of malposition and residual pneumothorax based on anterior and posterior insertion. Overall, there were 24 radiologic malpositions (32%) and 34 residual pneumothoraces
Table 2 The incidence of malposition and residual pneumothorax according to anterior and posterior insertion
Residual pneumothorax Radiological malposition Extrathoracic Parenchymal Interlobal Too deep Functional malposition
Anterior insertion (n = 32)
Posterior insertion (n = 42)
RR (95% CI)
P
7 (22%) 4 (13%) 0 0 2 (6%) 2 (6%) 2 (6%)
27 (64%) 20 (48%) 0 2 (5%) 18 (43%) 0 18 (43%)
3.04 (1.504-6.128) 3.36 (1.329-8.497) NA NA 5.56 (1.460-21.138) NA 5.18 (1.366-19.651)
b.001 .001 NA .502 b.001 .184 .001
(46%). Among the 24 chest tubes with a radiologic malposition, 20 (83%) were intrafissurally positioned, and 2 (8%) were intraparenchymally positioned. The remaining 2 (8%) had a malposition that was too deep and did not, therefore, belong to this study's classification. None were extrathoracically positioned. Among the 32 patients with an anterior insertion, 4 (13%) of the chest tubes were radiologically malpositioned, and no patients required the additional of a new drainage for hemothorax and residual pneumothorax. However, 2 (6%) required repositioning due to a malposition that was too deep. Among the 42 chest tubes with a posterior insertion, 20 (48%) had a radiologic malposition, and 18 (43%) had a functional malposition. The rates of both radiologic and functional malpositioning of the chest tubes with a posterior insertion were significantly higher than in patients with an anterior insertion (P b .01). A radiologic malposition does not necessarily indicate a functional malposition, because only chest tubes placed posteriorly (which did not involve radiologic malpositioning) caused a functional malposition (n = 7) (Fig. 1). 4. Discussion It is difficult to quickly judge the need for emergency thoracotomy. The ATLS guidelines suggested that operative exploration take place when (1) 1500 mL of blood is obtained immediately through the chest tube, (2) drainage of more than 200 mL/h for 2 to 4 hours occurs, or (3) blood transfusion is required [7]. Therefore, the chest tube plays a very important role in continuously monitoring blood loss. In some cases that are not resolved by a chest drain, the indication of thoracotomy should be evaluated in a comprehensive manner [8]. In our study, the presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation were found to be independent predictors for the development of MAH. If all 4 independent predictors were present, all patients developed MAH, and 71% of patients (5/7) required hemostatic intervention. It may, therefore, be possible to judge the need for emergency thoracotomy using these predictors without a chest tube. Chest tube insertion is a simple and definitive technique for most traumatic hemopneumothoraces [1,7], but it has a high complication rate [2,3,6,9,10]. When tube insertion is performed, malposition, injury to an intercostal artery, and lacerations of the lung, esophagus, stomach, liver, spleen, or diaphragm are all possible complications [9,11-13]. To avoid these complications, it is important that the attending physician receives appropriate training and exercise extreme care [6,14]. Malpositioning, which is one of the most common complications, can be identified using portable chest radiography in trauma care after the insertion is completed. By itself, however, this method is incapable of detecting all cases of malpositioning. In fact, the recent use of CT has identified a higher malposition rate (22%-53%) [2-6]. Malpositioning may be influenced by the specifics of the case, the insertion approach, and the physician's experience and expertise [6,14]. To our knowledge, this is the first study to analyze the malpositioning of chest tubes that has focused on different directions (posterior or anterior). Using a CT scan, Huber-Wagner et al [3] determined that the lateral approach tended to lead to an interlobal malposition more frequently than did the ventral approach. Therefore, a ventral approach may help to reduce the possibility of malpositioning. However, the ventral approach is not routinely recommended as it may be uncomfortable for the patient, injure the internal mammary artery, and damage the muscle and breast tissue, resulting in unsightly scarring [15]. It is also important to simplify the procedure in an urgent situation and use the lateral approach, although the “safe triangle” has been considered optimal in trauma patients [7,15]. In addition to this, a posterior insertion has the advantage of allowing for the monitoring of hemothoraces. In our study using the lateral approach, the malposition rate of anterior insertion, which did not use the ventral approach, was significantly lower than that of posterior insertion. We suspect that a chest tube in a posterior position may be predisposed toward malpositioning. If monitoring of
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blood loss is considered unnecessary in the early stage of initial trauma management, the risk of malposition may be reduced by using an anterior insertion. Of course, a posterior insertion cannot be completely ruled out because the chest tube may reduce the risk of retained hemothorax. However, the anterior chest tube may be able to more easily evacuate blood through postural changes. Our study has several limitations. First, the small sample size could also have magnified the effect of selection bias in our patients, and this study was not randomized in terms of chest tube insertion direction. The number of patients with MAH was only 18. It was difficult for the direction of the chest tube insertion to be randomized because the attending physician chose the direction in a case-by-case manner. Second, our study did not take into account the attending physicians' experience and the patients' severity. The complications of chest tube insertion may be strongly correlated with the physicians' experience and specialty [6]. Furthermore, the more severe the patient, the more necessary it is for the chest tube insertion to be quick and posteriorly oriented. The severity of the patients may be associated with the rate of malposition [2]. Third, the assessment of functional malposition was performed by the patient's attending physician. Immediately after insertion, it is difficult to determine whether the chest tube is functional or not. In addition, the attending physicians may consistently overrate the nonfunctionality of posterior directed chest tube insertion because of its high severity. The residual pneumothorax also existed in the course of lung expansion. Because a radiologic malposition did not always indicate a functional malposition, a radiologic malposition may not be problematic. 5. Conclusion The presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation are each predictors for the development of MAH in patients with traumatic pneumothorax. Posterior chest tubes have a high incidence of being malpositioned. Patients with traumatic pneumothorax do not necessarily require that the chest tube be directed posteriorly along the inside of the chest wall. Conflict of interest statement The authors declare that they have no competing interests.
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Author contributions All authors have read the manuscript and have approved its submission. In particular, SM conceptualized this study and was responsible for the design, data interpretation, and drafting of the manuscript. MK participated in the design of this study. MS participated in data collection. MY participated in the data interpretation. TF reported the CT imaging findings and participated in the design of this study. TO helped to draft the manuscript. KH provided advice about the analyzed data. KS critically revised the manuscript. MK provided final approval for its publication. References [1] Mattox KL, Moore EE, Feliciano DV. Trauma. 7th ed. McGraw-Hill; 2013. [2] Menger R, Telford G, Kim P, Bergey MR, Foreman J, Sarani B, et al. Complications following thoracic trauma managed with tube thoracostomy. Injury 2012;43:46–50. [3] Huber-Wagner S, Korner M, Ehrt A, Kay MV, Pfeifer KJ, Mutschler W, et al. Emergency chest tube placement in trauma care—which approach is preferable? Resuscitation 2007;72:226–33. [4] Lim KE, Tai SC, Chan CY, Hsu YY, Hsu WC, Lin BC, et al. Diagnosis of malpositioned chest tubes after emergency tube thoracostomy: is computed tomography more accurate than chest radiograph? Clin Imaging 2005;29:401–5. [5] Remerand F, Luce V, Badachi Y, Lu Q, Bouhemad B, Rouby JJ. Incidence of chest tube malposition in the critically ill: a prospective computed tomography study. Anesthesiology 2007;106:1112–9. [6] Ball CG, Lord J, Laupland KB, Gmora S, Mulloy RH, Ng AK, et al. Chest tube complications: how well are we training our residents? Can J Surg 2007;50:450–8. [7] American College of Surgeons Committee on Trauma. Advanced trauma life support (ATLS) for doctors; student course manual. 8th ed. Chicago, IL: American College of Surgeons; 2008 [editor]. [8] Nishiumi N, Inokuchi S, Oiwa K, Masuda R, Iwazaki M, Inoue H. Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma. Ann Thorac Surg 2010;89:232–8. [9] McFadden PM, Jones JW. Tube thoracostomy: anatomical considerations, overview of complications, and a proposed technique to avoid complications. Mil Med 1985; 150:681–5. [10] Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: complications and its management. Pulm Med 2012;2012:256878. [11] Meisel S, Ram Z, Priel I, Nass D, Lieberman P. Another complication of thoracostomy —perforation of the right atrium. Chest 1990;98:772–3. [12] Shapira OM, Aldea GS, Kupferschmid J, Shemin RJ. Delayed perforation of the esophagus by a closed thoracostomy tube. Chest 1993;104:1897–8. [13] Singh KJ, Newman MA. Pulmonary artery catheterization: an unusual complication of chest tube insertion. Aust N Z J Surg 1994;64:513–4. [14] Etoch SW, Bar-Natan MF, Miller FB, Richardson JD. Tube thoracostomy. Factors related to complications. Arch Surg 1995;130:521–5 [discussion 5–6]. [15] Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax 2003;58(Suppl. 2):ii53–9.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Chest tube insertion direction: is it always necessary to insert a chest tube posteriorly in primary trauma care?☆ Shokei Matsumoto, MD a,⁎, Kazuhiko Sekine, MD b, Tomohiro Funabiki, MD a, Motoyasu Yamazaki, MD a, Tomohiko Orita, MD a, Masayuki Shimizu, MD a, Kei Hayashida, MD a, Masanobu Kishikawa, MD c, Mitsuhide Kitano, MD a a b c
Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan Department of Emergency Medicine, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan Division of Emergency Medicine, Fukuoka City Hospital, Hakata-ku, Fukuoka-shi, Fukuoka, Japan
a r t i c l e
i n f o
Article history: Received 10 October 2014 Received in revised form 21 October 2014 Accepted 23 October 2014
a b s t r a c t Background: The advanced trauma life support guidelines suggest that, in primary care, the chest tube should be placed posteriorly along the inside of the chest wall. A chest tube located in the posterior pleural cavity is of use in monitoring the volume of hemothoraces. However, posterior chest tubes have a tendency to act as nonfunctional drains for the evacuation of pneumothoraces, and additional chest tube may be required. Thus, it is not always necessary to insert chest tubes posteriorly. The purpose of this study was to determine whether posterior chest tubes are unnecessary in trauma care. Methods: We reviewed the volume of hemothoraces from 78 chest drains emergently placed posteriorly at a primary trauma care in 75 blunt chest trauma patients who were consecutively admitted over a 6-year period, excluding those with cardiopulmonary arrest and occult pneumothoraces. Massive acute hemothorax (MAH), in which the chest tube should be inserted posteriorly, was defined as the evacuation of more than 500 mL of blood or the need for hemostatic intervention within 24 hours of trauma admission. Demographics, interventions, and outcomes were analyzed. We also reviewed the malpositioning of 74 chest tubes based on anterior and posterior insertion directions in patients who subsequently underwent computed tomography. Results: The overall incidence of MAH was 23% (n = 18). In the univariate analysis, the presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation were found to be independent predictors for the development of MAH. If all 4 independent predictors were absent, none of the patients developed MAH. The incidence of nonfunctional chest drains that required reinsertion or the addition of a new drainage was 27% (n = 20). The rates of both radiologic and functional malposition in chest tubes with posterior insertion were significantly higher than in patients with anterior insertion (64% and 43% vs 13% and 6%, respectively; P b .01). Conclusions: Chest tubes did not need to be directed posteriorly in many trauma cases. Posterior chest tubes have a high incidence of being malpositioned. This malpositioning may be prevented by judging the necessity for posterior insertion. © 2014 Elsevier Inc. All rights reserved.
1. Background Traumatic pneumothoraces and hemothoraces are major thoracic injuries that can be commonly treated with the insertion of a chest tube [1]. Unfortunately, it has been noted that malpositioned chest ☆ None of the authors have any conflicts of interest regarding any of the materials used in this study. ⁎ Corresponding author at: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012, Japan. Tel.: +81 45 576 3000; fax: +81 45 576 3586. E-mail addresses: [email protected] (S. Matsumoto), [email protected] (K. Sekine), [email protected] (T. Funabiki), [email protected] (M. Yamazaki), [email protected] (T. Orita), [email protected] (M. Shimizu), [email protected] (K. Hayashida), [email protected] (M. Kishikawa), [email protected] (M. Kitano). http://dx.doi.org/10.1016/j.ajem.2014.10.042 0735-6757/© 2014 Elsevier Inc. All rights reserved.
tubes and related complications occur at a high rate (22%-53%) [2-6]. The advanced trauma life support (ATLS) guidelines suggest that, in primary trauma care, the chest tube should be placed “posteriorly” along the inside of the chest wall because a chest tube located in the posterior pleural cavity is useful in monitoring the volume of hemothoraces [7]. Theoretically, chest tubes that are placed in the posterior pleural cavity have a tendency to act as nonfunctional drains for the evacuation of pneumothoraces, and chest tube reinsertion or addition may be required (Fig. 1). Naturally, a posteriorly inserted chest tube becomes a necessity in cases of hemothorax. There are, however, many cases of pneumothorax in which hemothorax is absent. Thus, we hypothesized that it is not always necessary to insert chest tubes posteriorly for traumatic pneumothoraces. The purpose of this study was to evaluate whether a posterior chest tube insertion was necessary in primary trauma care. This primary end point was
S. Matsumoto et al. / American Journal of Emergency Medicine 33 (2015) 88–91
89
A
B
Fig. 1. Computed radiography shows a nonfunctional chest tube inserted to evacuate pneumothoraces. The chest tube was directed posteriorly along the inside of the chest wall (arrowhead), and reinsertion of the tube proved necessary. Meanwhile, only 50 mL of blood was obtained through the chest tube 24 hours after admission.
designed to identify the incidence and corresponding risk factors for traumatic pneumothoraces in the presence of a hemothorax, which should be monitored. This secondary end point was designed to identify the incidence of malpositioned chest tubes based on different insertion directions using computed tomography (CT). 2. Methods 2.1. Patients and clinical management This noninterventional, observational study was conducted in the Emergency and Trauma Centre, a tertiary-care hospital in Japan from January 1, 2008, to December 31, 2013. Consecutive adult blunt trauma patients, who were diagnosed with traumatic pneumothoraces at a primary trauma survey using a chest x-ray, were prospectively enrolled. Patients who had cardiopulmonary arrest, hemothoraces without pneumothorax, and/or occult pneumothorax were excluded. In accordance with ATLS guidelines, all patients were examined and underwent a chest x-ray immediately upon admission. The presence of a pneumothorax was determined from the chest x-ray, and chest tubes were routinely inserted by a resident physician. Chest tubes ranging in size from 22F to 32F were directed posteriorly along the inside of the chest wall at the middle axillary lines (posterior insertion) or anteriorly along the inside of the chest wall at the anterior axillary lines (anterior insertion) using a blunt dissection technique (Fig. 2). The chest tube was managed with a water seal drainage system without suction (Chest Drainage Vac; Sumitomo Bakelite Co, Tokyo, Japan). The direction of tube insertion (posterior or anterior) was determined on a case-by-case basis after a review of the images and the clinical findings in primary trauma care. After chest tube insertion and resuscitation, CT scans were performed with 64 multidetector CT scanners (Aquilion CT scanner; Toshiba, Tokyo, Japan). 2.2. Data collection and definitions We collected the following data: demographics, injury severity score (ISS), the presence of rib fractures, shock, pulmonary opacities on chest x-ray, volume of hemothorax via chest tube, the need for intubation, hemostatic procedure, and outcomes. The necessity of posterior insertion for monitoring hemothorax was measured by the presence of massive acute hemothorax (MAH). Massive acute hemothorax was defined as the evacuation of more than 500 mL of blood, the need for the emergency hemostatic procedure, or adding another chest tube for hemothorax within 24 hours of trauma admission. The presence of
Fig. 2. The direction for inserting a chest tube using a blunt dissection technique. A, Anterior insertion, a chest tube is directed anteriorly along the inside of the chest wall at the anterior axillary lines. B, Posterior insertion, a chest tube is directed posteriorly along the inside of the chest wall at the middle axillary lines.
radiologic malposition and residual pneumothorax on CT scans was reported by an experienced faculty radiologist (TF). Malposition on CT was classified according to the previous report by Huber-Wagner et al [3] as extrathoracic, abdominal, parenchymal, or interlobal. Residual pneumothorax was defined as a thickness of 10 mm or more for the largest air collection along a line perpendicular from the chest wall to the lung. Furthermore, functional malposition was defined as a residual pneumothorax requiring clinical repositioning or the addition of a chest tube by the attending physician. 2.3. Statistical analysis The primary end point of the present portion of our study was the identification of the risk factors for the development of MAH for patients with traumatic pneumothorax. The secondary end point was the identification of the incidence of malpositioning (radiologic and functional) related to different chest tube insertion directions. We compared the demographic and clinical characteristics between patients who developed MAH and those who did not. For the univariate analysis, we used the χ 2 test with Yates correction for comparison of categorical risk factors and the Student t test for comparison of continuous risk factors. Relative risks (RRs) were calculated with the corresponding 95% confidence intervals (CIs). P b .050 was considered statistically significant. All statistical analyses were performed using SPSS for Windows version 15.0 (IBM, Armonk, NY). 3. Results During this study, a total of 4542 patients entered the emergency department (ED) as trauma victims, and 190 patients were diagnosed with traumatic pneumothorax. From this subset, 115 patients were excluded (17 patients who had cardiopulmonary arrest and 98 who had occult pneumothorax). The remaining 75 patients, with 3 of these patients having bilateral pneumothoraces, met our study criteria. All these enrolled patients received chest tubes in the ED. The 7 residents (4 in emergency medicine and 3 in general surgery) who performed the chest tube insertions had trained for an average of 3 years. 3.1. Predictors of massive acute hemothorax in the ED Table 1 summarizes the patient characteristics and outcomes of the study on MAH. The overall incidence of MAH was 23% (n = 18).
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Table 1 Comparison of characteristics and outcome in chest tubes with MAH or without MAH
Age, y Male, n (%) Right side, n (%) Pulmonary opacities on chest x-ray GCS ISS Rib fracture Multiple rib fractures Shock Positive pressure ventilation Hemostatic intervention Mortality, n (%)
MAH
Non-MAH
n = 18 (23%)
n = 60 (77%)
52.1 ± 17.6 16 (89%) 10 (56%) 11 (61%) 11.5 ± 4.2 32.4 ± 11.0 17 (94%) 16 (88%) 12 (67%) 15 (83%) 9 (50%) 4 (22%)
43.6 ± 17.2 50 (83%) 33 (55%) 3 (5%) 12.7 ± 3.6 26.8 ± 14.1 48 (80%) 30 (50%) 15 (25%) 22 (37%) 0 1 (2%)
P
.847 .722 .788 b.001 .245 .238 .278 .005 .002 .001 b.001 .009
Massive acute hemothorax was defined as more than 500 mL or the need for emergency thoracotomy for hemostasis or adding another chest tube for hemothorax within 24 hours of trauma admission. Values are expressed as mean ± SD or n (%).
Nine patients (50%) with MAH required an immediate hemostatic intervention in the form of exploratory thoracotomy (6 patients) or angioembolization (three patients). No patient without MAH required an immediate intervention. At the primary trauma care, the presence of multiple rib fractures (RR, 8.00; 95% CI, 1.69-37.87), shock (RR, 6.00; 95% CI, 1.92-18.78), pulmonary opacities on chest x-ray (RR, 29.86; 95% CI, 6.67-133.6), and the need for intubation (RR, 8.64; 95% CI, 2.25-33.12) were found to be independent predictors for the development of MAH. If all 4 independent predictors were absent, none of the patients developed MAH. In contrast, if all 4 independent predictors were present, all patients developed MAH, and 71% of the patients (5/7) required hemostatic intervention. 3.2. Malposition of chest tube from different directions (posterior or anterior) Overall, 4 patients could not be evaluated for malpositioning using a CT scan because 3 patients were managed with a chest tube insertion after the CT was performed and 1 patient was in a state of severe shock. Therefore, the remaining 71 patients, including the 3 patients with bilateral pneumothoraces, were included for evaluation of malpositioning. Of the 74 chest tubes inserted, 32 (46%) were inserted anteriorly, and 42 (60%) were inserted posteriorly. There were statistically significant differences in the severity between the 2 groups. Posterior insertion was chosen in patients who had a lower Glasgow Coma Scale (14 ± 3 vs 11 ± 4; P = .008), a higher incidence of shock (9% vs 55%; P b .001), and a higher ISS (22 ± 11 vs 34 ± 13; P b .001) compared with patients for whom anterior insertion was chosen. There was no difference in the sex, age, or mortality between the 2 groups. Table 2 shows the incidence of malposition and residual pneumothorax based on anterior and posterior insertion. Overall, there were 24 radiologic malpositions (32%) and 34 residual pneumothoraces
Table 2 The incidence of malposition and residual pneumothorax according to anterior and posterior insertion
Residual pneumothorax Radiological malposition Extrathoracic Parenchymal Interlobal Too deep Functional malposition
Anterior insertion (n = 32)
Posterior insertion (n = 42)
RR (95% CI)
P
7 (22%) 4 (13%) 0 0 2 (6%) 2 (6%) 2 (6%)
27 (64%) 20 (48%) 0 2 (5%) 18 (43%) 0 18 (43%)
3.04 (1.504-6.128) 3.36 (1.329-8.497) NA NA 5.56 (1.460-21.138) NA 5.18 (1.366-19.651)
b.001 .001 NA .502 b.001 .184 .001
(46%). Among the 24 chest tubes with a radiologic malposition, 20 (83%) were intrafissurally positioned, and 2 (8%) were intraparenchymally positioned. The remaining 2 (8%) had a malposition that was too deep and did not, therefore, belong to this study's classification. None were extrathoracically positioned. Among the 32 patients with an anterior insertion, 4 (13%) of the chest tubes were radiologically malpositioned, and no patients required the additional of a new drainage for hemothorax and residual pneumothorax. However, 2 (6%) required repositioning due to a malposition that was too deep. Among the 42 chest tubes with a posterior insertion, 20 (48%) had a radiologic malposition, and 18 (43%) had a functional malposition. The rates of both radiologic and functional malpositioning of the chest tubes with a posterior insertion were significantly higher than in patients with an anterior insertion (P b .01). A radiologic malposition does not necessarily indicate a functional malposition, because only chest tubes placed posteriorly (which did not involve radiologic malpositioning) caused a functional malposition (n = 7) (Fig. 1). 4. Discussion It is difficult to quickly judge the need for emergency thoracotomy. The ATLS guidelines suggested that operative exploration take place when (1) 1500 mL of blood is obtained immediately through the chest tube, (2) drainage of more than 200 mL/h for 2 to 4 hours occurs, or (3) blood transfusion is required [7]. Therefore, the chest tube plays a very important role in continuously monitoring blood loss. In some cases that are not resolved by a chest drain, the indication of thoracotomy should be evaluated in a comprehensive manner [8]. In our study, the presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation were found to be independent predictors for the development of MAH. If all 4 independent predictors were present, all patients developed MAH, and 71% of patients (5/7) required hemostatic intervention. It may, therefore, be possible to judge the need for emergency thoracotomy using these predictors without a chest tube. Chest tube insertion is a simple and definitive technique for most traumatic hemopneumothoraces [1,7], but it has a high complication rate [2,3,6,9,10]. When tube insertion is performed, malposition, injury to an intercostal artery, and lacerations of the lung, esophagus, stomach, liver, spleen, or diaphragm are all possible complications [9,11-13]. To avoid these complications, it is important that the attending physician receives appropriate training and exercise extreme care [6,14]. Malpositioning, which is one of the most common complications, can be identified using portable chest radiography in trauma care after the insertion is completed. By itself, however, this method is incapable of detecting all cases of malpositioning. In fact, the recent use of CT has identified a higher malposition rate (22%-53%) [2-6]. Malpositioning may be influenced by the specifics of the case, the insertion approach, and the physician's experience and expertise [6,14]. To our knowledge, this is the first study to analyze the malpositioning of chest tubes that has focused on different directions (posterior or anterior). Using a CT scan, Huber-Wagner et al [3] determined that the lateral approach tended to lead to an interlobal malposition more frequently than did the ventral approach. Therefore, a ventral approach may help to reduce the possibility of malpositioning. However, the ventral approach is not routinely recommended as it may be uncomfortable for the patient, injure the internal mammary artery, and damage the muscle and breast tissue, resulting in unsightly scarring [15]. It is also important to simplify the procedure in an urgent situation and use the lateral approach, although the “safe triangle” has been considered optimal in trauma patients [7,15]. In addition to this, a posterior insertion has the advantage of allowing for the monitoring of hemothoraces. In our study using the lateral approach, the malposition rate of anterior insertion, which did not use the ventral approach, was significantly lower than that of posterior insertion. We suspect that a chest tube in a posterior position may be predisposed toward malpositioning. If monitoring of
S. Matsumoto et al. / American Journal of Emergency Medicine 33 (2015) 88–91
blood loss is considered unnecessary in the early stage of initial trauma management, the risk of malposition may be reduced by using an anterior insertion. Of course, a posterior insertion cannot be completely ruled out because the chest tube may reduce the risk of retained hemothorax. However, the anterior chest tube may be able to more easily evacuate blood through postural changes. Our study has several limitations. First, the small sample size could also have magnified the effect of selection bias in our patients, and this study was not randomized in terms of chest tube insertion direction. The number of patients with MAH was only 18. It was difficult for the direction of the chest tube insertion to be randomized because the attending physician chose the direction in a case-by-case manner. Second, our study did not take into account the attending physicians' experience and the patients' severity. The complications of chest tube insertion may be strongly correlated with the physicians' experience and specialty [6]. Furthermore, the more severe the patient, the more necessary it is for the chest tube insertion to be quick and posteriorly oriented. The severity of the patients may be associated with the rate of malposition [2]. Third, the assessment of functional malposition was performed by the patient's attending physician. Immediately after insertion, it is difficult to determine whether the chest tube is functional or not. In addition, the attending physicians may consistently overrate the nonfunctionality of posterior directed chest tube insertion because of its high severity. The residual pneumothorax also existed in the course of lung expansion. Because a radiologic malposition did not always indicate a functional malposition, a radiologic malposition may not be problematic. 5. Conclusion The presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation are each predictors for the development of MAH in patients with traumatic pneumothorax. Posterior chest tubes have a high incidence of being malpositioned. Patients with traumatic pneumothorax do not necessarily require that the chest tube be directed posteriorly along the inside of the chest wall. Conflict of interest statement The authors declare that they have no competing interests.
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Author contributions All authors have read the manuscript and have approved its submission. In particular, SM conceptualized this study and was responsible for the design, data interpretation, and drafting of the manuscript. MK participated in the design of this study. MS participated in data collection. MY participated in the data interpretation. TF reported the CT imaging findings and participated in the design of this study. TO helped to draft the manuscript. KH provided advice about the analyzed data. KS critically revised the manuscript. MK provided final approval for its publication. References [1] Mattox KL, Moore EE, Feliciano DV. Trauma. 7th ed. McGraw-Hill; 2013. [2] Menger R, Telford G, Kim P, Bergey MR, Foreman J, Sarani B, et al. Complications following thoracic trauma managed with tube thoracostomy. Injury 2012;43:46–50. [3] Huber-Wagner S, Korner M, Ehrt A, Kay MV, Pfeifer KJ, Mutschler W, et al. Emergency chest tube placement in trauma care—which approach is preferable? Resuscitation 2007;72:226–33. [4] Lim KE, Tai SC, Chan CY, Hsu YY, Hsu WC, Lin BC, et al. Diagnosis of malpositioned chest tubes after emergency tube thoracostomy: is computed tomography more accurate than chest radiograph? Clin Imaging 2005;29:401–5. [5] Remerand F, Luce V, Badachi Y, Lu Q, Bouhemad B, Rouby JJ. Incidence of chest tube malposition in the critically ill: a prospective computed tomography study. Anesthesiology 2007;106:1112–9. [6] Ball CG, Lord J, Laupland KB, Gmora S, Mulloy RH, Ng AK, et al. Chest tube complications: how well are we training our residents? Can J Surg 2007;50:450–8. [7] American College of Surgeons Committee on Trauma. Advanced trauma life support (ATLS) for doctors; student course manual. 8th ed. Chicago, IL: American College of Surgeons; 2008 [editor]. [8] Nishiumi N, Inokuchi S, Oiwa K, Masuda R, Iwazaki M, Inoue H. Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma. Ann Thorac Surg 2010;89:232–8. [9] McFadden PM, Jones JW. Tube thoracostomy: anatomical considerations, overview of complications, and a proposed technique to avoid complications. Mil Med 1985; 150:681–5. [10] Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: complications and its management. Pulm Med 2012;2012:256878. [11] Meisel S, Ram Z, Priel I, Nass D, Lieberman P. Another complication of thoracostomy —perforation of the right atrium. Chest 1990;98:772–3. [12] Shapira OM, Aldea GS, Kupferschmid J, Shemin RJ. Delayed perforation of the esophagus by a closed thoracostomy tube. Chest 1993;104:1897–8. [13] Singh KJ, Newman MA. Pulmonary artery catheterization: an unusual complication of chest tube insertion. Aust N Z J Surg 1994;64:513–4. [14] Etoch SW, Bar-Natan MF, Miller FB, Richardson JD. Tube thoracostomy. Factors related to complications. Arch Surg 1995;130:521–5 [discussion 5–6]. [15] Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax 2003;58(Suppl. 2):ii53–9.
