Abstract
Traditional landmark thoracostomy technique has a known complication rate of 30%. While early data suggests that ultrasound can be a beneficial tool for identifying the correct thoracostomy tube insertions site, clinical studies are limited. We designed a pilot prospective randomized study to assess if ultrasound guidance can improve thoracostomy site identification over traditional landmark technique. 43 emergency medicine residents were randomly assigned to use either palpation or ultrasound to identify a safe insertion site for chest thoracostomy placement. We defined “safe” as above the diaphragm. The study was performed on a convenience sample reflecting a heterogenous mix of emergency department patients. The target patient population was comprised of hemodynamically stable trauma patients who received extended focused assessment with sonography in trauma (eFAST) and a chest computed tomography (CT) exam. The resident was instructed to place a small radiopaque marker on the skin of the patient where he/she believed was a safe intercostal space. Clinical ultrasound faculty then reviewed the chest CT to confirm radiopaque marker placement in relationship to the diaphragm. Fischer exact test was used to analyze the differences between the two groups. 97 patients were enrolled in the study resulting in the placement of 91 thoracostomy site markers by ultrasound and 89 by palpation. The average weight was 84kg with a BMI of 29kg/m2 (BSA 2.02) and these were comparable in both groups. The ultrasound group correctly identified thoracostomy tube insertions site above the diaphragm in 97.8% (89/91) of patients while landmark group identified a safe insertion site 89.9% (80/89) (p=0.0316). The ability to accurately locate a safe intercostal space for chest thoracostomy insertion was improved under ultrasound guidance. This technique is an excellent adjunct for novice providers and for patients with difficult landmarks or abnormal anatomy. Further studies are warranted to determine if this method can decrease complications with chest thoracostomy insertion.
Published Version
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