Institutional Guideline May Not Be Enough to Change Practice in the Management of Traumatic Hemothorax (HTX) and Pneumothorax (PTX) Management

Abstract

Traumatic hemothorax and pneumothorax (HTX/PTX) are traditionally treated with large-bore chest tubes, which can lead to pain and complications. Recent studies suggest pigtail catheters can be utilized as a non-inferior alternative. The Departments of Surgery and Emergency Medicine at NewYork Presbyterian – Weill Cornell Medical Center developed an institutional guideline to standardize tube size for treating traumatic HTX/PTX, aiming to reduce the use of large-bore thoracotomy tubes without causing adverse patient outcomes. This project at NYP-WCM included patients over 18 years of age admitted with thoracic injuries resulting in HTX or PTX treated with a chest tube from January 2022 to November 2023. Patients were identified through ICD codes in the trauma registry and electronic medical record. The primary outcome was adherence to the newly developed guideline for placing thoracostomy tubes. Conversion from pigtail to larger-bore chest tube and other adverse events were secondary outcomes. We identified 18 pre-guideline and 27 post-guideline HTX/PTX patients meeting the criteria. Before the guideline implementation, 15 out of 18 patients (83%) received care consistent with the guideline (no large-bore chest). After implementation, 25 out of 27 patients (93%) received care consistent with the guideline. Based on chart review, none of the patients in the pigtail cohort experienced complications or required conversion to a larger chest tube. Although the impact was modest, implementation of the institutional guideline correlates with a reduction in “unnecessary” large-bore chest tubes for treating traumatic HTX/PTX and showed a trend toward pigtail adoption. Placement of pigtails was not linked to negative complications or treatment failure, indicating a non-inferior safety and effectiveness profile for addressing traumatic HTX/PTX.