Abstract
BackgroundTraditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance.Methods33 emergency medicine residents and medical students volunteered to participate in this study during routine thoracostomy tube education. A healthy volunteer was used as the standardized patient for this study. An experienced physician sonographer used ultrasound to locate a site at mid-axillary line between ribs 4 and 5 and marked the site with invisible ink that can only be revealed with a commercially available UV LED light. Participants were asked to identify the thoracostomy site by placing an opaque marker where they would make their incision. The distance from the correct insertion site was measured in rib spaces. The participants were then given a brief hands-on training session using ultrasound to identify the diaphragm and count rib spaces. The participants were then asked to use ultrasound to identify the proper thoracostomy site and mark it with an opaque marker. The distance from the proper insertion site was measured and recorded in rib spaces.ResultsThe participants correctly identified the pre-determined intercostal space using palpation 48% (16/33) of the time, versus the ultrasound group who identified the proper intercostal space 91% (30/33) of the time. On average, the traditional technique was placed 0.88 rib spaces away (95 CI 0.43–1.03), while the ultrasound-guided technique was placed 0.09 rib spaces away (95 CI 0.0–0.19) [P = 0.003].ConclusionsThe ability to accurately locate the correct intercostal space for thoracostomy incision was improved under ultrasound guidance. Further studies are warranted to determine if this ultrasound-guided technique will decrease complications with chest tube insertion and improve patient outcomes.
Highlights
Thoracostomy tube placement became a mandatory skill for all providers taking care of trauma patients
This life-saving procedure has a complication rate up to 30% [7], with complications raging from tube malposition, to bleeding, and organ injury [8,9,10,11]
We designed a pilot study to test if ultrasound guidance improved proper thoracostomy site identification over traditional landmark technique in a healthy volunteer. Study design This was a simulation-based study in which observational results were collected during routine thoracostomy tube training of novice providers
Summary
Traditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance. In 1876, Hewett was the first to use a completely closed intercostal drainage system, [5] but it was not until World War II that tube thoracostomy became common in the treatment of injured patients [6]. From this point, thoracostomy tube placement became a mandatory skill for all providers taking care of trauma patients. Thoracostomy tube placement became a mandatory skill for all providers taking care of trauma patients This life-saving procedure has a complication rate up to 30% [7], with complications raging from tube malposition, to bleeding, and organ injury [8,9,10,11]
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