All posts by The Trauma Pro

Thorax

Chest Tube Size: The Argument That Never Dies

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I’ve written many posts in the past about the arguments surrounding chest tube size: large bore vs. small bore (pigtail). For the longest time, only a few decent papers were looking into this debate, and subject numbers were small. The best the papers could say was that “small-bore chest tubes are not inferior to large-bore tubes.” Not that this is not the same as saying, “small-bore tubes are better than large-bore tubes.”

But finally, after more than ten years, there has been enough written on the topic that a pass at a systematic review and meta-analysis has been attempted.  The University of Miami Ryder Trauma Center group performed a comprehensive review of the topic, spanning literature published through 2022.

Here are the factoids:

  • A total of 2008 articles were identified, but after careful screening, only 11 articles met predetermined parameters for inclusion
  • There were 3 randomized, controlled studies, 3 prospective cohort studies, and 5 retrospective cohort studies
  • Two pairs of studies had overlapping patients, so only patients in the more recent study of each was included
  • The authors used CASP scoring to judge the quality and likelihood of bias. Nearly all studies included were of high quality.

And here are the interesting findings:

  • There was no significant difference in failure rates between small and large tubes (18% vs. 22% )
  • There were no differences in complication rates (12% vs. 13% )
  • There was a significantly higher amount of initial drainage with the small tubes (750 cc vs 400 cc) (??)
  • Although the overall number of complications was the same, there were significantly more insertion complications in the small-bore group (4.4 vs 2.2). These included intra-hepatic placement, malpositioned tubes, kinked tubes, and dislodgement.
  • Only one study used a validated pain score to measure insertion pain, and there was no difference between the tube sizes
  • Tube days averaged 1.5 days less in the small-bore group, which was significant. However, this did not impact ICU or hospital length of stay.

Bottom line: There are still significant limitations in this study due to the small number of randomized controlled trials that are yet available. I also worry that there is some selection bias in many of the studies that would cause large-bore tubes to be inserted preferentially into patients with more severe chest trauma, larger hemothorax, or more emergent need for the tube. However, if there were major, major differences, they would probably be starting to rear their heads by now.

The authors of this paper concluded that “small bore tube thoracostomy may be as effective as large bore thoracostomy for the management of patients with hemothorax.” They correctly suggest that guided studies examining which patients are more suited for a specific sized tube. I totally agree.

For now, I still don’t think there is a definitive answer. I recommend that the bedside trauma professional use their judgment regarding patient condition, the magnitude of the chest trauma, and the urgency of the procedure to select a size. They must also consider their expertise with the tube selected to maximize effectiveness and minimize complications.

I’m sure there will be even more to write on this topic. It doesn’t seem to want to die.

Reference:  Small versus large-bore thoracostomy for traumatic hemothorax: A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery 97(4):p 631-638, October 2024. | DOI: 10.1097/TA.0000000000004412

Abdomen

Activity Guidelines After Solid Organ Injury: How Important Are They?

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Just about every practice guideline out there regarding liver and spleen injury has some physical activity restrictions associated with it. The accepted dogma is that moving around too much, climbing stairs, lifting objects, or getting tackled while playing rugby could exacerbate the injury and lead to complications or surgery.

But is it true? Activity restrictions after solid organ injury have been around longer than I have been a trauma surgeon. And the more people I poll on what they do, the more and very different answers I get. And there are no decent papers published that look critically at this question. Until now. 

A pediatric multi-center study of study on adherence to activity restrictions was published last year. Ten Level I pediatric trauma centers in the US tabulated their experience with solid organ injuries over 3.75 years from 2013 to 2016. Only patients with successful nonoperative management of their injury were included, and those with high-grade renal or pancreatic injuries were excluded.

Since this was a pediatric study, the American Pediatric Surgical Association (APSA) practice guideline was followed (activity restriction = organ injury grade + 2 weeks). Activity restrictions included all sports, any recreational activity with wheels, or any activity involving both feet off the ground. Patients with Grade III-V injuries were seen at an office visit after 2 weeks, and lower grade injuries had a phone follow-up.

Adherence to guidelines was assessed by a follow-up phone call two months after injury. Clinical outcomes assessed at 60 days included an unplanned return to the emergency department (ED), re-admission, complications, and development of new bleeding confirmed by surgery, ultrasound, or computed tomography (CT) at 60 days post-injury.

Here are the factoids:

  • Of the 1007 patients in the study, some 56% were either excluded (178) or lost to follow-up (463)
  • Of the remaining 366, roughly 46% had a liver injury, 44% spleen, and the remaining 10% had both
  • Median age was 10, so this was actually a younger population
  • 76% of patients claimed they abided by the guidelines, 14% said they did not, and 10% “didn’t know.” This means they probably did not.
  • For the 279 patients who said they adhered to activity restrictions, 13% returned to the ED, and half were admitted to the hospital
  • Of the 49 patients who admitted they did not follow the guidelines, 8% returned to the ED at some point, and none were readmitted
  • The most common reasons for returning to ED were abdominal pain, anorexia, fatigue, dizziness, and shoulder pain
  • There were no delayed operations in either of the groups

Bottom line: There were no significant differences between the compliant and noncompliant groups. Unfortunately, the authors did not include an analysis of the “I don’t know if I complied” group, which would have been interesting. However, there is one issue I always worry about in these low-number-of-subjects studies that don’t show a significant difference between groups. Did they have the statistical power to show such a difference? If not, then we still don’t know the answer. And unfortunately, I’m not able to guess the numbers well enough to do the power calculation for this study.

I am still intrigued by this study! Our trauma program originally set a fixed time period (6 weeks) of limited activity in our practice guideline for pediatric solid organ injury patients. This was reduced based on our experience of no delayed complications and guidance from our sister pediatric trauma center at Children’s Hospital in Minneapolis. We are also moving toward making a similar change to our adult practice guidelines. But even our current guideline of injury grade + 2 weeks is probably too much.

Too many centers wait too long to make changes in their practice guidelines. They bide their time waiting for new, published research that they can lean on for their changes. Unfortunately, they will be waiting for a long time because many of our questions are not interesting enough for acceptance by the usual journals. Rely on the expertise and experience of your colleagues and then make those changes. Be sure to follow with your performance improvement program to make sure that they actually do work as well as you think!

Reference: Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI). J Ped Surg 54:335-339, 2019.

General

Uber / Lyft For Medical Transport???

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In this day and age of ride-sharing apps like Uber and Lyft, it is possible to get a cheap ride virtually anywhere there is car service and a smartphone. And, of course, some people have used these services for transportation to the hospital instead of an ambulance ride. What might the impact of ride services on patient transport be for both patient and EMS?

Ambulance rides are expensive. Depending on region, they may range from $500-$5000. Although insurance may reduce out-of-pocket costs, it can still be costly. So what are the pros vs the cons of using Uber or Lyft for medical transport?

Pros:

  • Ride shares are inexpensive compared to an ambulance ride
  • They may arrive more quickly because they tend to circulate around an area, as opposed to using a fixed base
  • Riders may select their preferred hospital without being overridden by EMS (although it may be an incorrect choice)
  • May reduce EMS usage for low-acuity patients

Cons:

  • No professional medical care available during the ride
  • May end up being slower due to lack of lights and siren
  • Damage fees of $250+ for messing up the car

A fascinating paper suggests that ambulance service calls decreased by 7% after the introduction of UberX rides.  The authors mapped out areas where UberX rides were launching and examined emergency response data in these areas. They used a complex algorithm to examine trends over time in over 700 cities in the US and used several techniques to try to account for other factors. Here is a chart of the very fascinating results:

Bottom line: Uber and Lyft are just another version of the “arrival by private vehicle” paradigm. The use of these services relies on the customer/patient having very good judgment and insight into their medical conditions and care needs. And from personal experience, this is not always the case. I would not encourage the general public to use these services for medical transport, and neither do the companies themselves!

Reference: Did UberX Reduce Ambulance Volume? Health Econ 28(7)L817-829, 2019.

Prehospital

Field Amputation Part 6: The Procedure

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Preparation and planning will get you just so far. But then, you actually have to act. There are four phases in this procedure. I’ll break them down one by one.

Patient preparation. The area should be shielded from curious onlookers and to control any airborne contaminants (dust, debris) at the scene. Portable monitors should be attached. Good IV/IO access needs to be in place, and the airway controlled via intubation. Adequate anesthesia, analgesia, and sedation must be provided. In addition to pain medication, broad-spectrum antibiotics should be considered, and tetanus toxoid given at some point.

Limb preparation. Expose the extremity, especially the entire area around the amputation site. Wash gross debris off with saline. Place a tourniquet at least 2 inches proximal to the amputation site so it does not interfere with the procedure. Do not tighten until ready to begin. Then prep with betadine or other antiseptic.

The amputation. If that has not been done, administer anesthesia, and tighten the tourniquet. Choose an amputation point as distal as practical to preserve as much future function as possible. Generally speaking, a guillotine amputation is performed; nothing fancy here. Use large blades on the skin, and have plenty of extra blades. It is likely that the blades will get dull quickly in the scene environment. Cut through muscles next, saving the neurovascular bundles until last. These tend to retract when cut, so it is recommended that they be tied first.

Identify the spot where the bone will be cut, and scrape away the periosteum with the scalpel blade. Use an appropriate saw to actually separate the bone. Battery-powered hand-held saws are convenient and reduce the work. However, they may not readily fit into the space available, so a flexible wire (Gigli) saw may be preferred.

Always ensure that someone has been assigned to monitor the patient during the procedure. They need to ensure that everyone is aware of any adverse change in vital signs so that proper adjustments can be made.

Once the amputation is complete, inspect for bleeding, clamping anything that is a problem. It may not be possible to suture and tie given space limitations, so leaving the clamps in place works just fine. Then apply a bulky and compressive dressing, and get out of the way so the EMS providers can do their thing.

The aftermath. Once the patient has been extricated, double check the patient’s ABCs. Make sure the airway is well-placed and secure, or provide one now. Ensure adequate ventilation, and double-check for any bleeding from the amputation site or anywhere else. Then get the patient to definitive care so the trauma team can get to work.

But wait, what about the amputated part? If possible, it should be “dry-packed” in ice (remember the old bag within a bag?) and sent with the patient or soon after. Have you ever wondered why we do that? There is no hope for reimplantation, even if the amputation went flawlessly. There is little real return of function for extremities amputated above the fingers/toes. However, we can use skin and soft tissue from the lost part to help reconstruct the lost limb.

Click this link for a bibliography for this series.

Prehospital

Field Amputation Part 5: The Equipment

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We’ve covered all the preparation for field amputation. Now, it’s time to do it! But wait, exactly what equipment is needed? There are two principles that you must adhere to: figure it all out in advance, and keep it simple.

It is crucial that the trauma program design and assemble equipment and drug packs in advance, otherwise critical equipment may not make it to the field. The pack needs to be conveniently located, have fresh instruments and batteries for the equipment, and should have essential anesthetics included. I have included a link to a sample equipment at the end of the newsletter, and I encourage you to download and modify it to suit your needs.

Paralytics, sedatives and analgesics are essential. I prefer vecuronium, midazolam and fentanyl, but there are many other choices. I would discourage the use of propofol because it is difficult to titrate outside the hospital and may contribute to hypotension.

The patient should be intubated prior to starting the procedure. This airway may be difficult due to patient positioning, so be prepared to perform a surgical airway. Ketamine is a good drug in cases where intubation is not possible. Finally, don’t assume that the patient will be conveniently positioned supine. Rescue workers may need to support the patient (or you) if he or she is in an awkward position.

Finally, don’t assume that you will accompany the patient (and possibly their limb) back to the hospital. Based on the specific aircraft used, there may not be room available. You may return by ground transportation or another aircraft. That’s why the backup surgeon needs to be mobilized!

Click this link to a sample equipment list.

The next and final post will review the field amputation procedure.