Pre-hospital and in-hospital thoracostomy: indications and complications.
BACKGROUND
Pleural drainage with chest tube insertion for thoracic trauma is a common and often life-saving technique. Although considered a simple procedure, complication rates have been reported to be 2-25%. We conducted a prospective cohort observational study of emergency pleural drainage procedures to validate the indications for pre-hospital thoracostomy and to identify complications from both pre- and in-hospital thoracostomies.


METHODS
Data were collected over a 7-month period on all patients receiving either pre-hospital thoracostomy or emergency department tube thoracostomy. Outcome measures were appropriate indications, errors in tube placement and subsequent complications.


RESULTS
Ninety-one chest tubes were placed into 52 patients. Sixty-five thoracostomies were performed in the field without chest tube placement. Twenty-six procedures were performed following emergency department identification of thoracic injury. Of the 65 pre-hospital thoracostomies, 40 (61%) were for appropriate indications of suspected tension pneumothorax or a low output state. The overall complication rate was 14% of which 9% were classified as major and three patients required surgical intervention. Twenty-eight (31%) chest tubes were poorly positioned and 15 (17%) of these required repositioning.


CONCLUSIONS
Pleural drainage techniques may be complicated and have the potential to cause life-threatening injury. Pre-hospital thoracostomies have the same potential risks as in-hospital procedures and attention must be paid to insertion techniques under difficult scene conditions. In-hospital chest tube placement complication rates remain uncomfortably high, and attention must be placed on training and assessment of staff in this basic procedure.
Aylwin
Christopher J
CJ
Trauma Service, Department of Surgery, Royal London Hospital, London, UK. cjaylwin@doctors.org.uk
Brohi
Karim
K
Davies
Gareth D
GD
Walsh
Michael S
MS
D000328:Adult; D015505:Chest Tubes / Q000706:statistics & numerical data; D015331:Cohort Studies; D004322:Drainage / Q000295:instrumentation / Q000379:methods; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006491:Hemothorax / Q000601:surgery; D006801:Humans; D008131:London; D008297:Male; D011030:Pneumothorax / Q000601:surgery; D011446:Prospective Studies; D013898:Thoracic Injuries / Q000601:surgery*; D013907:Thoracostomy / Q000009:adverse effects / Q000379:methods*