Computed tomography-detected hemothorax after blunt chest trauma: Does everyone need an intervention? A retrospective analysis.

Thoracic trauma resulting in hemothorax (HTx) is typically managed with thoracostomy tube (TT) placement; however, up to 20% of patients develop retained HTx which may necessitate further intervention for definitive management. Although optimal management of retained HTx has been extensively researched, little is known about prevention of this complication. We hypothesized that thoracic irrigation at the time of TT placement would significantly decrease the rate of retained HTx necessitating secondary intervention. A prospective, comparative study of patients with traumatic HTx who underwent bedside TT placement was conducted. The control group consisted of patients who underwent standard TT placement, whereas the irrigation group underwent standard TT placement with immediate irrigation using 1 L of warmed sterile 0.9% saline. Patients who underwent emergency thoracotomy, those with TTs removed within 24 hours, or those who died within 30 days of discharge were excluded. The primary end point was secondary intervention defined by additional TT placement or operative management for retained HTx. A propensity-matched analysis was performed with scores estimated using a logistic regression model based on age, sex, mechanism of injury, Abbreviated Injury Scale chest score, and TT size. In over a 30-month period, a total of 296 patients underwent TT placement for the management of traumatic HTx. Patients were predominantly male (79.6%) at a median age of 40 years and were evenly split between blunt (48.8%) and penetrating (51.2%) mechanisms. Sixty (20%) patients underwent thoracic irrigation at time of initial TT placement. The secondary intervention rate was significantly lower within the study group (5.6% vs. 21.8%; OR, 0.16; p < 0.001). No significant differences in TT duration, ventilator days, or length of stay were noted between the irrigation and control cohort. Thoracic irrigation at the time of initial TT placement for traumatic HTx significantly reduced the need for secondary intervention for retained HTx. Therapeutic Study, Level III.

Hemothorax is a common sequelae following thoracic trauma and is associated with significant morbidity and mortality. Current guidelines recommend all traumatic hemothoraces be considered for drainage with tube thoracostomy (TT), regardless of size. With increasing use of computed tomography, smaller hemothoraces not seen on x-ray (defined as an occult hemothorax) are frequently detected. This systematic review was performed to gather data on patients with occult hemothorax managed with TT or without TT (termed expectant management [EM]). MEDLINE, EMBASE, and Cochrane databases from inception to October 2019 were searched for relevant articles. The primary outcome was rates of failure of expectant (conservative) management. Secondary outcomes of interest included predictors of TT insertion, predictors of failure of EM, and morbidity and mortality in patients with occult hemothorax. We screened 1,329 abstracts from which 6 articles reporting 1,405 patients with occult hemothorax were included. Of these patients, 601 (43.68%) were managed initially with TT, and 802 (56.32%) were managed expectantly. Of the 802 patients managed expectantly, 212 failed conservative management and underwent TT insertion (23.1% pooled failure rate estimate [95% confidence interval, 17.1-29.1%]). The presence of concomitant pneumothorax predicted upfront TT insertion. Of the patients who failed EM, the need for mechanical ventilation and the presence of a large hemothorax predicted failure. Mortality was similar in both groups. Conservative treatment of occult hemothorax fails in 23.1% of patients. The presence of hemothorax greater than 300 mL and the need for mechanical ventilation predicted failure of conservative treatment and the need for TT. There was no difference in mortality between EM and TT cohorts. These data suggest that it may be possible to safely observe patients with occult hemothoraces less than 300 mL (1.5 cm pleural stripe) secondary to blunt trauma without upfront TT insertion. Systematic review and meta-analysis, level III.

Traumatic pneumothoraces occur in 25% of patients sustaining traumatic chest injury. Tube thoracostomy carries a risk of major complications leading to the necessity of tube thoracostomy insertion for traumatic pneumothoraces to be challenged. This meta-analysis analyses current evidence relating to the management of traumatic pneumothorax and synthesises the evidence to determine whether clinicians can safely omit tube thoracostomy in patients with traumatic pneumothorax presenting to the Emergency Department (ED). This meta-analysis was performed by searching electronic databases. Papers were included for analysis if they used patients sustaining blunt trauma and compared tube thoracostomy to conservative management. Comparisons were made for those undergoing tube thoracostomy and those undergoing conservative management. Fourteen studies comprising 1550 patients were included. There is a non-significant combined pneumothorax progression rate of 12% for those observed, and 7.6% for those with a tube thoracostomy (p = 0.8447) with an odds ratio of 1.33. There was an 11.9% rate for tube thoracostomy insertion among patients observed, and a 10.4% requirement for further tube thoracostomy placement in those already with a tube thoracostomy (p = 0.3436) with an odds ratio of 0.553. For patients receiving positive pressure ventilation, the rates were 18% in observed patients compared to 9% of those with a tube thoracostomy (p = 0.2848) with an odds ratio of 4.123. Conservative management of traumatic pneumothorax without positive pressure ventilation is a reasonable initial safe approach in the ED. Only ~12% of these patients will eventually require a tube thoracostomy.

Blunt chest trauma and tube thoracostomy

The Volume of Thoracic Irrigation Is Associated With Length of Stay in Patients With Traumatic Hemothorax

Pain Management Guidelines for Blunt Thoracic Trauma Bruce Simon;James Cushman;Robert Barraco;Vivian Lane;Fred Luchette;Maurizio Miglietta;David Roccaforte;Ruth Spector; The Journal of Trauma: Injury, Infection, and Critical Care

Thoracic irrigation prevents retained hemothorax: a pilot study

Background: We aimed to assess the management and outcome of occult pneumothorax and to determine the factors associated with failure of observational management in patients with blunt chest trauma (BCT). Methods: Patients with BCT were retrospectively identified from the trauma database over 4 years. Data were analyzed and compared on the basis of initial management (conservative vs. tube thoracostomy). Results: Across the study period, 1928 patients were admitted with BCT, of which 150 (7.8%) patients were found to have occult pneumothorax. The mean patient age was 32.8 ± 13.7 years, and the majority were male (86.7%). Positive-pressure ventilation (PPV) was required in 32 patients, and bilateral occult pneumothorax was seen in 25 patients. In 85.3% (n = 128) of cases, occult pneumothorax was managed conservatively, whereas 14.7% (n = 22) underwent tube thoracostomy. Five patients had failed observational treatment requiring delayed tube thoracostomy. Pneumonia was reported in 12.8% of cases. Compared with those who were treated conservatively, patients who underwent tube thoracostomy had thicker pneumothoraxes and a higher rate of lung contusion, rib fracture, pneumonia, prolonged ventilatory days, and prolonged hospital length of stay. Overall mortality was 4.0%. The deceased had more polytrauma and were treated conservatively without a chest tube. Patients who failed conservative management had a higher frequency of lung contusion, greater pneumothorax thickness, higher Injury Severity Scores (ISS), and required more PPV. Conclusions: Occult pneumothorax is not uncommon in BCT and can be successfully managed conservatively with a close clinical follow-up. Intervention should be limited to patients who have an increase in size of the pneumothorax on follow-up or become symptomatic under observation. Patients who fail conservative management may have a greater pneumothorax thickness and higher ISS. However, large prospective studies are warranted to support these findings and to establish the institutional guidelines for the management of occult pneumothorax.

Tube thoracostomy (TT) insertion can serve as a life-saving adjunct for thoracic trauma. Unfortunately, suboptimal positioning using the open, standard of care technique is associated with complications resulting in impaired TT function. Using a porcine model, we aimed to determine whether a magnetic chest tube positioning system (MCTPS) could be utilized to direct the intrathoracic TT position. Using recently deceased cross-bred domestic swine, we performed TT using our MCTPS and the standard of care open technique. The operator held one magnet outside of the thorax. The second magnet was positioned at the distal aspect of the TT. The operator was tasked with positioning the TT to distinct premarked intra-thoracic locations under blinded conditions. The experiment was video-recorded through an open sternotomy incision. As a control, TT was inserted using the standard of care open technique. The utilization of MCTPS successfully directed TT from one premarked location to another in 4 of 5 attempts (80%). Conversely, the control TT without magnetic guidance failed to navigate the premarked intra-thoracic locations with 0 of 5 attempts successful (p = 0.05). Positional flaws after TT placement are common. We demonstrate the feasibility of the MCTPS as an alternative to traditional hand-guided technique under simulated TT insertion conditions. The MCTPS is possibly superior to the current standard of care technique of TT. Additional studies are needed to develop this emerging technology in humans.

Tube thoracostomy (TT) can be an effective therapy for thoracic pathologies. Ineffective placement of TT is common and associated with significant complications. Complications require additional interventions to repair damaged tissues or replace dysfunctional TT. We hypothesize that complicated TT insertion increases cost to the hospital system. Adult trauma patients requiring TT at a level 1 trauma center (2012-2013) were reviewed. Intraoperative or image-guided TT placements were excluded. Baseline demographics and TT insertion cost (normalized and assigned by hospital billing records) were recorded. Costs included initial TT equipment, radiographs, and subsequent operative or radiologic intervention to correct TT complications. Complications were categorized using previously validated method. Secondary outcomes included: number of TT inserted, number of chest radiographs performed, and TT dwell time utilizing a standardized TT discontinuation protocol. A total of 154 patients with 246 TT were included. Ninety TT (37%) had complication. Complication categories are postremoval (n=15, 16.7%), insertional (n=13, 14.4%), positional (n=62, 68.9%). Overall median complicated TT cost was 9 times greater than uncomplicated TT insertion, p=0.001. Insertional complications median cost 21 times greater than an uncomplicated, due to operative and radiologic interventions (p=0.0001). Positional and postremoval complication rates increased median cost by 3 times compared to uncomplicated TT (p=0.03). Operative or radiologic interventions (n=10) were performed for organ injury or uncontrolled hemo-/pneumothorax. Increased dwell time median [IQR] was associated with complicated TT compared to uncomplicated 3 [1-5] versus 2 [1-3], p=0.01. TT is a common procedure. TT complications are often considered benign. However, patients with a complicated TT insertion, especially related to insertional subtypes, have markedly increased hospitalization costs due to need for operative or radiologic repair. Level V-retrospective study. This is a retrospective single-institution study.

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. 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. 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). 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. Prognostic, level IV.

Chest trauma in childhood is relatively uncommon in clinical practice, and has been the subject of few reports in the literature. This study was undertaken to examine our experience in dealing with chest trauma in children. This was a retrospective study of 74 children who sustained chest trauma, and were referred to King Fahad Hospital in Medina over a two-year period. The age, cause of injury, severity of injury, associated extrathoracic injuries, treatment and outcome were analyzed. The median age of the patients was nine years. Fifty-nine of them (80%) sustained blunt trauma, and 15 (20%) were victims of penetrating injuries. Road traffic accident was the cause of chest trauma in 62% of the children, gun shot wounds were seen in five, and stab wounds in 10 children. Head injury was the most common injury associated with thoracic trauma, and was seen in 14 patients (19%), and associated intraabdominal injuries were seen in nine patients. Chest x-ray of the blunt trauma patients revealed fractured ribs in 24 children, pneumothorax in six, hemothorax in four, hemopneumothorax in three, and pulmonary contusions in 22 patients. Fifty-one percent of children were managed conservatively, 37% required tube thoracostomy, 8% were mechanically ventilated, and 4% underwent thoracotomy. The prevalence of chest trauma in children due to road traffic accidents is high in Saudi Arabia. Head injury is thought to be the most common associated extrathoracic injuries, however, most of these patients can be managed conservatively.

Background: Blunt chest trauma is one of the leading causes of post-traumatic death in both developed and developing countries. Pneumothorax is a common injury after blunt chest trauma. It occurs when there are signs of air remaining in the pleural cavity after injury, even though the pleural cavity does not communicate with the outside environment. Diagnosis is based on signs and symptoms, including chest pain, shortness of breath, hyperresonant to percussion, decreased breath sounds, decreased tactile fremitus. Chest X-rays are essential for diagnosis, and chest computed tomography can provide more accurate results. Treatment methods vary but often involve pleural drainage as a primary and important step, in addition to options such as conservative treatment or surgery. Objectives: To study the clinical, imaging features, and treatment results of pneumothorax in blunt chest trauma. Materials and methods: All patients with pneumothorax in blunt chest trauma were treated at Can Tho Central General Hospital from April 2022 to April 2023. Results: The average age was 45.95 ± 18.16 years. Men constituted 89% of the patient population, and traffic accidents were the cause in 86% of cases. Chest pain and dyspnea were two common symptoms of pneumothorax after blunt chest trauma, accounting for 91.9% and 40.5%, respectively. The incidence of rib fractures is quite high, accounting for 83.8% of cases. Out of 37 cases, one case was managed conservatively, while pleural drainage was performed in 36 cases (97.3%). Among the cases requiring pleural drainage, three cases (8.3%) required thoracotomy. The overall treatment success rate was 100%, with an average hospital stay of 8.3 ± 3.5 days. The presence of more or fewer rib fractures can impact the treatment duration for the patient, as 78.6% of patients with more than 4 broken ribs had a hospital stay of at least 8 days. Conclusion: Pneumothorax is a common injury following blunt chest trauma, and it occurs more frequently in men than women. The prevalent clinical features include chest pain, dyspnea, decreased breath sounds, and subcutaneous emphysema. The age of the patient and the number of fractures also impact the time required for treatment of this condition.

Tube thoracostomy (TT), considered a routine procedure, has significant complications. Current recommendations for placement rely on surface anatomy. There is no information to guide operators regarding angle of insertion relative to chest wall. We aim to determine if angle of insertion is associated with complications of TT. We performed a retrospective review of adult trauma patients who necessitated TT at a Level I trauma center over a 2-year period (January 2012 to December 2013). Tube thoracostomies performed intraoperatively or using radiological guidance were excluded. Thoracic anteroposterior or posteroanterior radiographs were reviewed to determine the angle of insertion of TT relative to the thoracic wall. A previously validated classification method was used to categorize complications. Descriptive and univariate statistics were used to compare angle of insertion and complicated versus uncomplicated TT. Review identified 154 patients who underwent a total of 246 TT placed for emergent trauma. All patients had a postprocedural chest x-ray. We identified 90 complications (37%) over the study period. One hundred forty-four of the TTs reviewed had an angle of insertion less than 45 degrees of which there were 27 complications (19%). One hundred two of the TTs had an angle greater than 45 degrees and 63 complications (62%); p < 0.0001. Tube thoracostomy insertion is inherently dangerous. Placement of TT using a higher angle of insertion greater than 45 degrees is associated with increased complications. Further prospective studies quantifying TT angle of insertion on outcomes are needed. Therapeutic study, level IV.

Background: In chest trauma, the conditions that compromise breathing very fast include hemothorax (HTx), pneumothorax (PTx), or both (HPTx). Fortunately, these conditions can be managed with tube thoracostomy (TT). This study was performed to determine whether TT position affects the rate of secondary intervention. Patients and Method: We studied adult trauma patients who underwent TT placement over a period of one year (from March 2017 to March 2018) in 3 Nigerian teaching hospitals. Classification of tube placement by radiologist was considered as ideal when the tube was apically directed and placed in the pleural cavity. Non-ideal TT was defined within the fissure or supradiaphragmatic position. The primary outcome was defined as TT replacement, additional TT tube insertion, or surgical intervention. Results: Ninety seven chest trauma patients who underwent TT placement. Indications for placement were HPTx (43.2%), HTx (26.8%), and PTx (30.0%). Majority of patients were male (66%), median age of 40.8 years (IQR 16–55 years), and blunt (71.1%) trauma. Ideal TT positioning was found in 76 (78.4%) and non-ideal 21 (21.6%). Secondary intervention rate was 4 (19.0%) including 3 (14.25%) replaced TT and 1 (4.75%) thoracotomy. Rate of secondary intervention for ideal and non-ideal TT position was 1 (1.0%) and 19.0% (P = 0.009), respectively. The difference in rate of secondary intervention was not significant (25.1% vs 34.1%, P = 0.09). Conclusion: Position of a non-kinked TT with the sentinel hole within the thoracic cavity does not affect secondary intervention rates. Given over 20% of individuals with additional TT placement required operative intervention for definitive management, early operative intervention in the setting of non-kinked TT provides ideal patient care.