Thoracentesis Research Articles

Abstract 247: Chest Tube Insertion, Needle Thoracostomy, And Pericardiocentesis During In-hospital Cardiac Arrest

Introduction: Some causes of cardiac arrest, e.g. cardiac tamponade or tension pneumothorax, can only be reversed by an emergent invasive procedure; identification and treatment of these causes is critical during cardiopulmonary resuscitation. The use of emergent procedural interventions has not been comprehensively studied in the setting of in-hospital cardiac arrest (IHCA). Methods: Using the American Heart Association sponsored Get With The Guidelines ® -Resuscitation registry, we examined adult patients who received an invasive procedure (chest tube insertion (CTI), needle thoracostomy (NT), and/or pericardiocentesis (PC)) during IHCA between 2001 and 2020. Groups were compared using Fisher’s exact test for categorical variables and t-test or rank-sum for continuous variables. Outcomes were compared using multivariate hierarchical modeling accounting for clustering by hospital. Results: Of the 482,972 patients with IHCA, 11,304 (2.34%) had a procedure performed (1.24% CTI, 0.46% NT, 0.63% PC). PEA was a more likely initial rhythm in those who received a procedure compared to those who had no procedure (58.2% vs 47.8%, p<0.01), and VT or VF was less likely (8.8% vs 16.9%, p<0.01). Peri-arrest myocardial infarction was more likely in those who received PC compared to no procedure (21.7% vs 15.0%, p<0.01). Those who received CTI or NT were more likely to be on a ventilator than those with no procedure (67.9% vs 49.7%, p<0.01). The mean duration of resuscitation was longer for those with CTI, NT, and PC (29.0 min, 29.0 min, and 33.6 min) than for those who had no procedure (18.6 min, p<0.01). Patients who received CTI, NT, and PC had 7%, 20%, and 27% lower odds of ROSC respectively than patients who had no procedure (aOR 0.93, 95%CI 0.91 - 0.95, p<0.01; aOR 0.80, 95%CI 0.78 - 0.82, p<0.01; aOR 0.73, 95%CI 0.71 - 0.74, p<0.01), and 5%, 10%, and 12% lower odds of survival to discharge (aOR 0.95, 95%CI 0.94 - 0.96, p<0.01; aOR 0.90, 95%CI 0.89 - 0.92, p<0.01; aOR 0.88, 95%CI 0.87 - 0.89, p<0.01). Conclusions: We found important differences in patient characteristics and outcomes for those who received invasive procedures compared to those with no procedure. Those who received invasive procedures during IHCA had longer resuscitations but less ROSC and survival to discharge.

Acute Mediastinal Bleeding with Pleural Escape: Case Report of a Rare Interventional Complication with Unusual Resolve

AbstractAcute mediastinal bleeding is a very rare complication of cardiac intervention. It is a life-threatening situation when this condition causes acute compression of the mediastinal area. A 59-year-old man was diagnosed with inferior ST-elevation myocardial infarction with ongoing chest pain and underwent an urgent percutaneous coronary intervention procedure. After coronary stent was implanted, patient complained of chest tightness, and suffocation, blood pressure dropped, O2 saturation dropped, and was difficultly intubated. Image acquisition by C-arm showed a large bulging in aortic arch area. Contrast-enhanced computed tomography ruled out aortic dissection, but noted a large mediastinal mass that was radiated to the neck. The bulging was spontaneously regressed, and a large left pleural effusion was developed. Left pleural tapping was performed on day 7, and a total of 1.5-L hemorrhagic fluid was evacuated. In our case, unusual drainage from mediastinal to pleural space has probably save the patient.

P259 Rare presentations of Cryptococcosis: a case series

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives Cryptococcus spp. is usually opportunistic pathogens affecting immunocompromised individuals causing meningitis primarily. Non-CNS presentations are a rare entity and we hereby present a series of 3 cases in the past 1 year (2021-2022).MethodsCase records of the three patients were studied. Detailed history, demographic details, investigations, treatment were noted.ResultsPatient-1 was a 14-year-old girl who came with complaints of fever, pain, swelling, and restricted movements of the right wrist, elbow, and ankle joints with multiple subcutaneous swellings initially on the thigh followed by elbows, arms, and forearms. The swellings became hemorrhagic bullae bursting to form ulcers. She had a history of being treated 4 times for tuberculous lymphadenopathy. KOH-Calcofluor white mount of biopsy and pus aspirate samples showed circular yeast cells which were confirmed by cryptococcal antigen detection. All the samples had grown Cryptococcus neoformans on culture except blood, BAL, and CSF. She responded to Liposomal amphotericin-B drastically. Retesting of pus swabs from the ulcers after a week of antifungal therapy were negative for C. neoformans. Subcutaneous nodules and joint swellings decreased but she developed reactions to amphotericin B and was changed to fluconazole. She is on regular follow-up with no recurrence.Patient-2 was a 22-year-old male, a known case of Hodgkin Lymphoma stage 4 who underwent Autologous stem cell transplantation (ASCT) and was on immunosuppressants. He presented with fever, dyspnea, and cough which got worsened along with multiple cervical, hilar and abdominal lymphadenopathy. KOH-Calcofluor white mount of biopsy samples demonstrated circular yeast cells which were confirmed by cryptococcal antigen detection test of biopsy and BAL samples. Cryptococcus neoformans was grown on culture from all the samples. He succumbed to ARDS and cardiorespiratory arrest before any treatment could be initiated.Patient-3 was a 38-year-old female, known case of SLE with lupus nephritis, presented with intermittent fever, dyspnea, chest pain, decreased urinary output, and gradual swelling of the body starting from the face and progressing to the whole body. She further developed synpneumonic effusion, multiple erythematous tender papules over the right thigh, and cellulitis of the right lower limb. She was started on voriconazole in view of HRCT findings suggestive of fungal pneumonia. As galactomannan antigen test was negative, voriconazole was stopped. Pleural tap fluid flagged positive in Bactec and C. neoformans grown on subculture. Her condition worsened with septic shock and succumbed to the disease before any treatment could be initiated.ConclusionSubcutaneous, joint, and pulmonary involvement is rare, without a primary focus on the central nervous system. Culture and antigen detection can aid in early detection and hence early initiation of therapy.

Tubercular pleural effusion with epithelioid cells– A rare cytological case presentation

Tuberculosis is one of the most prevalent disease of the developing countries resulting in significant morbidity. Extra pulmonary tuberculosis results in pleurisy among predilection to other organ and organ systems like lymph nodes. Pleurisy results in tubercular pleural effusion. Pleural effusions are mostly seen in immunocompetent patients. Here we present a case of tubercular pleural effusion which was diagnosed by cytology examination of pleural fluid in a 22-year-old female, who presented with shortness of breath, generalized weakness with decreased appetite. Radiological investigations revealed a unilateral pleural effusion. Pleural tapping was done and sent for cytological examination. Cytospin aspirate smear showed degenerated mesothelial cells, histiocytes, few epithelioid cells, mature lymphocytes and lymphocytes with splintered chromatin. A diagnosis of tubercular pleural effusion was made with further tests like CBNAAT for confirmation of diagnosis. CBNAAT was positive with a strain of Rifampicin sensitive mycobacterial tuberculosis identified. Patient was started on anti tubercular drugs according to the National Tuberculosis Elimination Program. To conclude, cytology is a fast inexpensive method for diagnosing the etiology of pleural effusions by pointing us in the right direction.

FINGER: A Novel Approach to Teaching Simple Thoracostomy

For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax.

Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults.

We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy. In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique. Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85). There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

Paramedic Understanding of Tension Pneumothorax and Needle Thoracostomy (NT) Site Selection.

IntroductionTension pneumothorax is an immediate threat to life. Treatment in the prehospital setting is usually achieved by needle thoracostomy (NT). Prehospital personnel are taught to perform NT, frequently in the second intercostal space (ICS) at the mid-clavicular line (MCL). Previous literature has suggested that emergency physicians have difficulty identifying this anatomic location correctly. We hypothesized that paramedics would also have difficulty accurately identifying the proper location for NT.MethodsA prospective, observational study was performed to assess paramedic ability to identify the location for treatment with NT. Participants were recruited during a statewide Emergency Medical Services (EMS) conference. Subjects were asked the anatomic site for NT and asked to mark the site on a shirtless male volunteer. The site was copied onto a transparent sheet lined up against predetermined points on the volunteer’s chest. It was then compared against the correct location that had been identified using palpation, measuring tape, and ultrasound.Results29 paramedics participated, with 24 (83%) in practice for more than five years and 23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) reported training in NT, although six (21%) had never performed a NT in the field. Nine paramedics (31%) recognized the second ICS at the MCL as the desired site for NT, with 12 (41%) specifying only the second ICS, 11 (38%) specifying second or third ICS, and six (21%) naming a different location (third, fourth, or fifth ICS). None (0%) of the 29 paramedics identified the exact second ICS MCL on the volunteer. Mean distance from the second ICS MCL was 1.37 cm (interquartile range (IQR): 0.7-1.90) in the medial-lateral direction and 2.43 cm in the superior-inferior direction (IQR: 1.10-3.70). Overall mean distance was 3.12 cm from the correct location (IQR: 1.90-4.50). Most commonly, the identified location was too inferior (93%). Allowing for a 2 cm radius from the correct position, eight (28%) approximated the correct placement. 25 (86%) were within a 5 cm radius.ConclusionIn this study, paramedics had difficulty identifying the correct anatomic site for NT. EMS medical directors may need to rethink training or consider alternative techniques.

Emergency Critical Skills Training for Pre-clinical Physician Assistant Students: Mixed Method Comparison of Training Method

IntroductionThe fast-paced nature of physician assistant (PA) programs warrants an emphasis on high-fidelity, critical care skills training. Generally, manikins or task trainers are used for training and assessing. Soft-preserved cadavers provide a high-fidelity model to teach high-acuity, low-opportunity procedures; however, their effectiveness in PA pre-clinical training is not well understood.ObjectiveThis study compared procedural competency of task trainer and soft-preserved cadaver trained pre-clinical PA (pcPA) students in completing tube thoracostomy, endotracheal intubation, intraosseous infusion, and needle thoracostomy.MethodsA randomized controlled study was conducted with pcPA students (n = 48) at a midwestern program. Participants were randomly assigned to cadaver trained (CT), task trainer (TT), or control group (CG). We assessed procedural competency using skill-specific rubrics and performed qualitative analysis of student comments regarding skill-specific procedural preparedness.ResultsIntervention groups surpassed the control group on all skills. The CT students exhibited significantly higher procedural competency compared to TT-trained students in endotracheal intubation (p = 0.0003) and intraosseous infusion (p = 0.0041). Thematic analysis of student comments revealed pre-training students consistently felt unprepared and lacked confidence to perform needle thoracostomy, tube thoracostomy, and endotracheal intubation. Post-training perceptions, CT/TT, focused on preparedness and confidence. The CT group also consistently described the impact of realistic simulation.ConclusionHigh-fidelity training with soft-preserved cadavers may be the most effective way to prepare pcPA students to perform endotracheal intubation and intraosseous infusion. Student perspectives on procedural preparedness highlight the importance of multidimensional, realistic training methods.

Post-mortem computed tomography assessment of medical support device position following fatal trauma: a single-center experience.

To evaluate the percentage of misplaced medical support lines and tubes in deceased trauma patients using post-mortem computed tomography (PMCT). Over a 9-year period, trauma patients who died at or soon after arrival in the emergency department were candidates for inclusion. Whole body CT was performed without contrast with support medical devices left in place. Injury severity score (ISS) was calculated by the trauma registrar based on the injuries identified on PMCT. The location of support medical devices was documented in the finalized radiology reports. A total of 87 decedents underwent PMCT, of which 69% (n = 60) were male. For ten decedents, the age was unknown. For the remaining 77 decedents, the average age was 48.4 years (range 18-96). The average ISS for the cohort was 43.4. Each decedent had an average of 3.3 support devices (2.9-3.6, 95% CI), of which an average of 1 (31.3%, 0.8-1.2, 95% CI) was malpositioned. A total of 60 (69.0%) had at least one malpositioned medical support device. The most commonly malpositioned devices were decompressive needle thoracostomies (n = 25/32, 78.1%). The least malpositioned devices were intraosseous catheters (n = 7/69, 10.1%). Nearly one quarter (n = 19/82, 23.2%) of mechanical airways were malpositioned, including 4.9% with esophageal intubation. Malpositioned supportive medical devices are commonly identified on post-mortem computed tomography trauma decedents, seen in 69.0% of the cohort, including nearly one quarter with malpositioned mechanical airways. Post-mortem CT can serve as a useful adjunct in the quality improvement process by providing data for education of trauma and emergency physicians and first responders.

Prehospital portable ultrasound for safe and accurate prehospital needle thoracostomy: a pilot educational study

BackgroundSimulated needle thoracostomy (NT) using ultrasound may reduce potential injury, increase accuracy, and be as rapid to perform as the traditional landmark technique following a brief educational session. Our objective was to determine if the use of an educational session demonstrating the use of handheld ultrasound to Emergency Medical Services (EMS) staff to facilitate NT was both feasible, and an effective way of increasing the safety and efficacy of this procedure for rural EMS providers.MethodsA pre/post-educational intervention on a convenience sample of rural North American EMS paramedics and nurses. Measurement of location and estimated depth of placement of needle thoracostomy with traditional landmark technique was completed and then repeated using handheld ultrasound following a training session on thoracic ultrasound and correct placement of NT.ResultsA total of 30 EMS practitioners participated. Seven were female (23.3%). There was a higher frequency of dangerous structures underlying the chosen location with the landmark technique 9/60 (15%) compared to the ultrasound technique 1/60 (1.7%) (p = 0.08). Mean time-to-site-selection for the landmark technique was shorter than the ultrasound technique at 10.7 s (range 3.35–45 s) vs. 19.9 s (range 7.8–50 s), respectively (p < 0.001). There was a lower proportion of correct location selection for the landmark technique 40/60 (66.7%) when compared to the ultrasound technique 51/60 (85%) (p = 0.019). With ultrasound, there was less variance between the estimated and measured depth of the pleural space with a mean difference of 0.033 cm (range 0–0.5 cm) when ultrasound was used as compared to a mean difference of 1.0375 cm (range 0–6 cm) for the landmark technique (95% CI for the difference 0.73–1.27 cm; p < 0.001).ConclusionsTeaching ultrasound NT was feasible in our cohort. While time-to-site-selection for ultrasound-guided NT took longer than the landmark technique, it increased safe and accurate simulated NT placement with fewer identified potential iatrogenic injuries.

Pleural Effusions and Pericarditis: A Retrospective Cohort Study of Patients Undergoing Cardiac Magnetic Resonance Imaging.

BackgroundPleural effusions can occur due to acute pericarditis and can necessitate intervention. We sought to add to the evidence base by performing a retrospective review of patients presenting to the advanced cardiac imaging unit with pericarditis and pleural effusion to determine laterality, trends in pleural fluid analyses, and the need for pleural intervention. Local ethical (Caldicott) approval was obtained for this study.MethodologyDescriptive statistical methodology was applied with continuous data presented as mean (standard deviation, SD; range) and categorical variables as frequencies or percentages.ResultsIn 60 patients with pericarditis, 24 (39%) had pleural effusions on contemporaneous imaging. The mean age of the study population was 63.3 years (range: 20-83), and 17 patients were males. Diagnoses were viral (five), rheumatological (one), amyloidosis (one), listeria (one), and the rest idiopathic (17). Four effusions were only left-sided, one right-sided, and 20 bilateral. Ten pleural taps were performed, one for a unilateral effusion and nine for one side being bigger than the other. The mean pH was 7.46 (7.33-7.6), mean lactate dehydrogenase was 210 (74-393 U/L), mean fluid protein was 36.1 (19-56 g/L) (four effusions exudative/three transudative), mean glucose was 5.8 (4.8-6.8 mmol/L), and all cytologies were negative. Five patients underwent large volume aspirations for symptom control. Three indwelling pleural catheters (IPC) were placed for treatment refractory effusions. There was one pleural space infection in six months related to an IPC. There were three deaths at 12 months, with none related to pericarditis.ConclusionsPleural effusions associated with pericarditis are usually small, bilateral, and exudative. Treatment refractory cases require pleural intervention, with aspirations, drains, and IPCs being viable options. Further prospective studies are warranted.

C-MAC video laryngoscopy in a difficult airway in a child with nephrotic syndrome with croup and severe neck oedema.

Sir, A 10-year-old boy, a known case of focal segmental glomerulosclerosis, presented to the paediatric emergency with generalised anasarca, neck swelling for seven days, and severe respiratory distress for one day. On examination, the child was conscious, preferentially adopted the sitting posture, and had neck swelling extending up to the sternal angle. His peripheral oxygen saturation (SpO2) was 96% on room air. His neck girth was 40 cm (normal: 26.4-27.2 cm).[1] His height and weight were appropriate for age and sex. Air entry was reduced in bilateral subscapular and interscapular regions. Shifting dullness was present on abdominal examination. The provisional diagnosis was nephrotic syndrome with relapse with bilateral pleural effusion, ascites, and fluid collection in the neck with a probable local-site infection. His investigations revealed hypoproteinaemia, hypercholesterolemia and heavy proteinuria. Frontal view of the chest radiogram revealed the ‘steeple sign’ which was consistent with the diagnosis of acute laryngotracheobronchitis [Figure 1a]. The neck ultrasound showed subcutaneous oedema with fluid extension into the muscular plane. Needle aspirate of the neck swelling, diagnostic pleural and ascitic tap were transudate in nature.Figure 1: (a) Frontal chest X-ray showing ‘steeple sign’ (black solid arrow) with neck oedema till T4 (white arrows) and bilateral pleural effusion (black open arrows); (b) Resolution of ‘steeple sign’, neck oedema and pleural effusion in the index caseDue to increasing neck oedema, impending respiratory failure and anticipated difficult airway, the child was planned for tracheal intubation, in the operating theatre (OT), by a multidisciplinary team consisting of paediatricians, intensivists and otorhinolaryngologist. Tracheostomy consent was taken prior to the procedure. Intravenous glycopyrrolate 0.1 mg was given 30 min before shifting to the OT. SpO2 in the OT was recorded as 86% on room air and 98% on oxygen supplementation. On direct laryngoscopy, mouth opening was equal to 2.5 finger breadths. After opening of mouth and maximum protrusion of the tongue, only soft palate and base of uvula could be seen. Floor of the mouth was not elevated. There was severe glottic oedema with a narrow glottic opening. These findings suggested difficult intubation (Mallampati class III). Pre-oxygenation was done for 3 min, and intravenous midazolam and fentanyl were administered. Injection propofol followed by succinylcholine was given. Four to five low tidal volume breaths were given by face mask ventilation with ease. An attempt at conventional intubation by direct laryngoscopy failed due to poor visibility and narrow glottis. However, he was successfully intubated using C-MAC video laryngoscope (Karl Storz, Tuttlingen, Germany) with acute angle D-blade in combination with Frova introducer with cuffed endotracheal tube of 5 mm internal diameter. The child was shifted to paediatric intensive care unit and put on synchronised intermittent mandatory ventilation mode. Additionally, he was given corticosteroids, albumin infusions and supportive care. He recovered fully after few weeks [Figure 1b]. Neck girth normalised to 27 cm at discharge. The child was regularly followed-up and did well. Croup or laryngotracheobronchitis, a common paediatric emergency, is usually managed with steroids and adrenaline nebulisation. However, less than 2% children with croup require intubation.[2] In our child, glottic oedema due to croup and neck oedema due to relapse of nephrotic syndrome contributed to the difficult airway. Difficult direct laryngoscopy is encountered in 0.06 to 3% children.[3] Failed intubation, a life-threatening situation for the patient, requires anticipation and preparedness. Video laryngoscope is a newer generation device for management of the difficult airway. The presence of a camera at the light source helps in better visualisation of glottis for intubation.[4] Additionally, a Frova introducer aids in entry into the glottis due to its flexible distal tip with a 30° anterior angulation and has an adaptor that allows to oxygenate. It also reduces the risk of tissue damage and bleeding with video laryngoscope.[5] Awake fibreoptic bronchoscopy was not an option in this case due to excessive irritability and age of the child.[56] To conclude, clinical parameters like increased neck circumference of 40 cm or more, and progressive worsening signs like worsening SpO2, and respiratory distress helped us to anticipate a difficult airway and arrange a backup of video laryngoscope.[13] Alternative approaches of securing the airway like video laryngoscopy may be useful in cases of an anticipated difficult airway in children. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Empyema Thoracis Caused by Klebsiella Spp and Escherichia coli Co-Infection - An Uncommon Isolation with Atypical Presentation

Empyema thoracis is the collection of pus in the pleural space. A 9-year-old boy presented with a 3-day history of high grade continuous fever, a day history of abdominal pain, distension and fast breathing. Examination findings: acutely ill child, febrile, in respiratory distress. Chest findings: tachypnea, dull percussion note and decreased air entry on the right hemithorax. Chest radiograph: massive fluid collection in the right hemithorax. A pleural tap yielded frank pus that was sent for microscopy, culture and sensitivity (MCS). Escherichia coli was cultured which was sensitive to fluoroquinolones. Klebsiella spp was also cultured from the blood sample taken for MCS and yielded the same sensitivity. Patient responded well to tube thoracostomy drainage and administration of antibiotics. Empyema thoracis with the isolation of two-gram negative organisms in a previously healthy child is rare.

Prehospital Simple Thoracostomy Does Not Improve Patient Outcomes Compared to Needle Thoracostomy in Severely Injured Trauma Patients.

ATLS suggests simple thoracostomy (ST) after failure of needle thoracostomy (NT) in thoracic trauma. Some EMS agencies have adopted ST into their practice. We sought to describe our experience implementing ST in the prehospital setting, hypothesizing that prehospital ST would reduce failure rates and improve outcomes compared to NT. This was a retrospective review of adult trauma patients who received prehospital ST or NT from 2017 to 2020. There were 48 patients with 64 procedures included. 83.7% were male and 65.8% injured by penetrating mechanism and of median (IQR) age of 31 (25-46)years. 28 (43.8%) procedures were NT and 36 (56.3%) were ST. Rates of improved patient response (P = .15), noted return of blood/air (P = .19), and return of spontaneous circulation (P = .62) did not differ. On-scene times were higher for ST (16.8 vs 11.5minutes; P < .02). Overall mortality did not differ between ST and NT (68.2% vs 46.4%, respectively; P = .125). For patients that survived beyond the ED, procedure-related complication rates were 2 of 21 patients (9.5%) in ST and 1 of 12 (8.3%) in NT. In penetrating trauma, simple thoracostomy had longer on-scene time and total prehospital time. ST did not improve success rates of ROSC and was associated with prolonged prehospital times, especially in penetrating trauma patients. Given the benefit of "scoop and run" in urban penetrating trauma, consideration should be given to direct transport in lieu of ST. Use of ST in blunt trauma should be evaluated prospectively.

Ten-year reduction in thoracic injury-related mortality among Israel Defense Forces soldiers

IntroductionThis study aims to describe injury patterns, prehospital interventions and mortality rates of combat-related thoracic injuries during the past decade among Israel Defense Forces (IDF) soldiers before and after implementation...

Abstract 11681: An Extremely Rare Case of Intercostal Artery Rupture After Percutaneous Coronary Intervention

Introduction: There are a few case reports of Intercostal artery injury after pleural tap and trauma but none after a PCI. Case: A 61-year-old Caucasian male with PMH of T2DM, Hypertension, Hyperlipidemia, former tobacco chewing, family history of premature CAD presented to ED with midsternal chest pressure of 2 hours and three weeks of dyspnea on exertion. He was seen earlier in the outpatient office where an ECHO showed an EF of 55%, and a Nuclear stress test showed moderate inferior ischemia. CT coronary Angiogram showed complex plaques in Mid RCA and mid LAD. Troponin and EKG were normal. A diagnosis of unstable angina was suspected, and he was loaded with clopidogrel and heparin drip. He underwent emergency cardiac catheterization via a trans-radial approach. The standard J wire was switched to an angled-tip stiff Terumo guidewire due to difficulty traversing the aortic arch. The guidewire briefly went down the descending thoracic aorta. There was complex, eccentric stenosis of 99% in mid LAD and mid-RCA, which were stented with DES. The patient developed right chest pain radiating to his back. He became hypotensive, and Hemoglobin dropped from 13 to 8g/dl. CT scan showed a large right-sided hemothorax, and a chest tube was placed. He was resuscitated, and Angiogram showed three pseudoaneurysms and rupture of the right 8 th intercostal artery with active contrast extravasation. The right 9 th intercostal artery had one pseudoaneurysm. Both the vessels were embolized by an interventional radiologist. Discussion: Intercostal arteries arise from descending thoracic aorta. It is likely the catheter advanced into the descending aorta and the intercostal artery resulting in injury. Proper guidewire advancement under fluoroscopy and confirming the position of guidewire before advancing the guiding catheter may prevent this complication. Prompt recognition and emergency treatment with a chest tube and IR-guided embolization should be done.

SPONTANEOUS PNEUMOMEDIASTINUM SECONDARY TO COVID-19 INFECTION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: SARS-CoV-2 (COVID-19) is a rapidly spreading virus that has resulted in a pandemic. Individuals impacted have varying symptoms and disease courses, ranging from asymptomatic carriers to severe respiratory illness. Pneumomediastinum, a rare complication of COVID-19 (where air is present in the mediastinum with or without pneumothorax) is presented here. CASE PRESENTATION: Our case is that of a 59-year-old man who presented to the emergency department with complaints of fever and chills for five days. His past medical history included hypertension, type 2 diabetes mellitus and hyperlipidemia. He endorsed associated dry cough, decreased appetite and shortness of breath. He denied recent travel or exposure to COVID-19. Initially the patient was hemodynamically stable, but hypoxic with oxygen saturation of 82%, requiring 4L nasal cannula (NC) – with improvement to 93-95%. Chest imaging revealed low lung volumes and patchy bilateral opacities. COVID-19 PCR was positive. He was admitted to the medical floor with acute COVID-19 pneumonia. He was treated with dexamethasone and remdesivir, and was encouraged to self-prone. Due to worsening hypoxia, he required a non-rebreather mask. Daily chest x rays were obtained, and on hospital day seven, imaging revealed air around the neck, suggesting pneumomediastinum without pneumothorax. CT chest and neck showed significant air dissecting up from the superior mediastinum, extending through the neck soft tissues bilaterally, confirming acute pneumomediastinum. With further pulmonary decompensation and respiratory failure, he required intubation and mechanical ventilation. A low PEEP strategy was employed to prevent worsening pneumomediastinum. In the subsequent week, although his pneumomediastinum resolved, the patient unfortunately developed ARDS and passed away. DISCUSSION: This presentation of acute pneumomediastinum in the setting of COVID-19 is an uncommon complication of the viral illness. Diffuse alveolar damage and/or complication of mechanical ventilation have been speculated to be possible causes. Pneumomediastinum is typically a benign diagnosis, but can sometimes progress to malignant mediastinum, where air compresses the trachea or venous return, which can in turn present as cardiac tamponade. In these cases, chest tube, VATS or thoracotomy may be indicated.1 CONCLUSIONS: Cases of pneumomediastinum in patients infected with COVID-19 are limited, hence its impact on worsening illness or outcome cannot be determined. Recommendations continue to focus on close monitoring with daily chest imaging. Should intubation be required, it is recommended to maintain a needle at bedside for needle thoracostomy in the event acute pneumothorax occurs.2 A low tidal volume, low PEEP strategy is also encouraged to mitigate risk of further barotrauma.3 Early paralysis may be beneficial to prevent coughing or ventilator dyssynchrony. REFERENCE #1: Kouritas VK, Papagiannopoulos K, Lazaridis G, et al. Pneumomediastinum. J Thorac Dis. 2015;7(Suppl 1):S44-S49. doi:10.3978/j.issn.2072-1439.2015.01.11 REFERENCE #2: Mousa S, Edriss H. Pneumomediastinum secondary to invasive and non-invasive mechanical ventilation. The Southwest Respiratory and Critical Care Chronicles. 2019;7(27), 36-42. https://doi.org/10.12746/swrccc.v7i27.524 REFERENCE #3: Wali A, Rizzo V, Bille A, Routledge T, Chambers A. Pneumomediastinum following intubation in COVID-19 patients: a case series. Anaesthesia. 2020;75: 1076-1081. https://doi.org/10.1111/anae.15113 DISCLOSURES: No relevant relationships by James McGee, source=Web Response No relevant relationships by Cilian White, source=Web Response No relevant relationships by Momina Zaman, source=Web Response

Complications and Outcomes of Diaphragm Surgeries in Epithelial Ovarian Malignancies.

To achieve optimal debulking, cytoreductive surgery often involves diaphragm stripping. We describe our complications and survival outcomes after diaphragm surgery in epithelial ovarian cancer. A retrospective analysis on patients with advanced stage epithelial ovarian cancer between January 2012 and September 2019. The details of the diaphragmatic resections and stripping and their complications were looked into. During the study period, 616 patients with epithelial ovarian cancers were operated of which, 81 (13.2%) had diaphragm surgery. The majority underwent diaphragm stripping (60%) while 33% had resection and 7% cases had diaphragmatic nodule excision. Optimal debulking was achieved in 89% of cases. The complexity of surgery was intermediate in 64% of patients and complex in 33% as per Aletti's scoring. Mean operating time was 300min (SD113). Moderate to severe pleural effusion was seen in 26 (32. %) patients necessitating pleural tapping in 16% and single lumen pleurex catheter insertion in 11%. Median recurrence-free and overall survival were 22 (95% CI 16.9-27) and 32months (95% CI 25.5-38) respectively. Diaphragm stripping and resection is an important step in achieving optimal debulking of advanced and recurrent ovarian cancer. Diaphragmatic disease clearance is a necessary skill to be acquired by the gynaecologic oncology surgeons. Choosing the patients correctly and anticipation of complications can reduce morbidity and mortality.

Pediatric Patients Undergoing Surgery with Peroperative SARS-Cov-2 Infection: An Iranian Case Brief Report:

Introduction: The present study aimed to assess COVID-19 disease complications and its related 30-day mortality in pediatric patients with perioperative SARS-CoV-2 infection who had surgery. Materials and Methods: A multi-center, prospective, brief report of pediatric patients who had surgery at 6 hospitals in 4 cities of Khuzestan Province, South-western Iran, one of the provinces with the highest prevalence and death rates due to COVID-19 disease. COVID-19 status and its effect on the course and outcome of the patients was investigated. Results: 246 pediatric patients who had surgery between Jan 20 and Jun 01, 2020 with a 30-day follow-up period enrolled in the study. Four (1.62%) of the 246 patients who underwent surgery had perioperative COVID-19 infection. The most common symptoms included dyspnea, fever, and cough. Surgical procedures included total gastrectomy and esophagojejunostomy, bilateral pleural effusions tap, catheter placement for dialysis, and CV-line placement. Three patients had comorbidities including congestive heart failure (CHF), end-stage renal disease (ESRD), and diabetes. Conclusion: Based on our results, it can be said that the prevalence of this disease in children is lower than the average of the society; and the outcome in younger patients seems to be better. Though it seems that COVID-19 disease is a low risk and somehow benign condition in children undergoing surgery, but due to the unpredictable nature of the disease, public health recommendations at both general and special levels have been made by the World Health Organization (WHO) to prevent the disease. Further studies with larger samples are necessary to confirm our findings and to clarify which age groups are at increased risk for developing severe COVID-19 infection and its related morbidities and death.

ABCL-087: Lymphocytic Pleural Effusion: An Unusual Initial and Isolated Presentation of Non-Hodgkin Lymphoma

Pleural involvement from diffuse large B-cell lymphoma (DLBCL) has been reported in the literature, and it is associated with poor outcome. However, non-Hodgkin lymphoma presenting as an isolated pleural effusion is unusual. Here we report the case of 84-year-old female patient, without past medical history, who presented for worsening shortness of breath. Investigations were pertinent for a left pleural effusion without other clinically significant findings in the laboratory and radiological work-up. A left pleural thoracentesis showed a lymphocytic exudative effusion. The complete screening for fungal or bacterial etiologies, including mycobacterium tuberculosis, was negative. The cytology didn't reveal any abnormal or malignant cells. Unfortunately, the effusion worsened 48 hours after the prior pleural tap. We repeated the thoracentesis, and we were able to obtain a cell block. Microscopic evaluation and immunohistochemistry were relevant for numerous intermediate to large-sized tumor cells with round nuclei; they stained positive for CD20, multiple myeloma-1 (MUM1), B-cell chronic lymphocytic leukemia/lymphoma (Bcl6), Bcl2, and negative for CD3, CD138, CD10. The Ki67 was 95%. Thus, she was diagnosed with DLBCL involving the left pleura. 18-fluorodeoxyglucose (FDG) PET-CT scan showed an isolated hypermetabolic left pleural effusion without any other nodal or skeletal uptake. Bone marrow biopsy was negative for any lymphomatous infiltration. Taking into consideration her age, she was started on R-mini-CHOP chemotherapy protocol with drastic improvement of the pleural effusion after the first session. She completed 6 cycles of R-mini-CHOP with primary G-CSF prophylaxis and is currently in complete remission. Although it is a rare entity, isolated pleural DLBCL should be considered whenever we have a non-resolving lymphocytic pleural effusion. Clinicians and pathologists must be aware of this diagnosis which is made by cytopathology, immunohistochemistry, and flow cytometry on pleural fluid.