title: Chest tube insertion direction: is it always necessary to insert a chest tube posteriorly in primary trauma care?
abstract: BACKGROUND
  The advanced trauma life support guidelines suggest that, in primary care, the chest tube should be placed posteriorly along the inside of the chest wall. A chest tube located in the posterior pleural cavity is of use in monitoring the volume of hemothoraces. However, posterior chest tubes have a tendency to act as nonfunctional drains for the evacuation of pneumothoraces, and additional chest tube may be required. Thus, it is not always necessary to insert chest tubes posteriorly. The purpose of this study was to determine whether posterior chest tubes are unnecessary in trauma care.
  
  
  METHODS
  We reviewed the volume of hemothoraces from 78 chest drains emergently placed posteriorly at a primary trauma care in 75 blunt chest trauma patients who were consecutively admitted over a 6-year period, excluding those with cardiopulmonary arrest and occult pneumothoraces. Massive acute hemothorax (MAH), in which the chest tube should be inserted posteriorly, was defined as the evacuation of more than 500 mL of blood or the need for hemostatic intervention within 24 hours of trauma admission. Demographics, interventions, and outcomes were analyzed. We also reviewed the malpositioning of 74 chest tubes based on anterior and posterior insertion directions in patients who subsequently underwent computed tomography.
  
  
  RESULTS
  The overall incidence of MAH was 23% (n = 18). In the univariate analysis, the presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation were found to be independent predictors for the development of MAH. If all 4 independent predictors were absent, none of the patients developed MAH. The incidence of nonfunctional chest drains that required reinsertion or the addition of a new drainage was 27% (n = 20). The rates of both radiologic and functional malposition in chest tubes with posterior insertion were significantly higher than in patients with anterior insertion (64% and 43% vs 13% and 6%, respectively; P < .01).
  
  
  CONCLUSIONS
  Chest tubes did not need to be directed posteriorly in many trauma cases. Posterior chest tubes have a high incidence of being malpositioned. This malpositioning may be prevented by judging the necessity for posterior insertion.
authors.affiliation: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan. Electronic address: m-shokei@feel.ocn.ne.jp.
authors.forename: Shokei
authors.initials: S
authors.lastname: Matsumoto
authors.affiliation: Department of Emergency Medicine, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan. Electronic address: skkazoo@yahoo.co.jp.
authors.forename: Kazuhiko
authors.initials: K
authors.lastname: Sekine
authors.affiliation: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan. Electronic address: funabiki@jf7.so-net.ne.jp.
authors.forename: Tomohiro
authors.initials: T
authors.lastname: Funabiki
authors.affiliation: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan. Electronic address: motoyasu@sc.itc.keio.ac.jp.
authors.forename: Motoyasu
authors.initials: M
authors.lastname: Yamazaki
authors.affiliation: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan. Electronic address: oritaer@yahoo.co.jp.
authors.forename: Tomohiko
authors.initials: T
authors.lastname: Orita
authors.affiliation: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan. Electronic address: masayukizc4@yahoo.co.jp.
authors.forename: Masayuki
authors.initials: M
authors.lastname: Shimizu
authors.affiliation: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan. Electronic address: keilinda@s6.wh.qit.ne.jp.
authors.forename: Kei
authors.initials: K
authors.lastname: Hayashida
authors.affiliation: Division of Emergency Medicine, Fukuoka City Hospital, Hakata-ku, Fukuoka-shi, Fukuoka, Japan. Electronic address: kishikawam@aqr.bbiq.jp.
authors.forename: Masanobu
authors.initials: M
authors.lastname: Kishikawa
authors.affiliation: Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Tsurumi-ku, Yokohama, Kanagawa, Japan. Electronic address: mitsu-kitano@mtd.biglobe.ne.jp.
authors.forename: Mitsuhide
authors.initials: M
authors.lastname: Kitano
mesh_terms: D000328:Adult; D015505:Chest Tubes; D005260:Female; D006491:Hemothorax / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy*; D006801:Humans; D015994:Incidence; D007564:Japan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013898:Thoracic Injuries / Q000150:complications*; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000150:complications*