Traditionally, hemothorax and pneumothorax in trauma has been treated with chest tubes. I’ve previously written about some of the debate regarding using smaller tubes or catheters. A paper that will be presented at the EAST meeting in January looked at pain and failure rates using 14Fr pigtail catheters vs 28Fr chest tubes.
This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.
The following interesting findings were noted:
- Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
- Tube site pain was significantly less with the pigtail
- The failure rate was the same (5-10%)
- Complication rate was also the same (10%)
- Time that the tube was in, and hospital stay was the same
Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.
Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, 2013.
I showed you this x-ray the other day, and asked what the problem was.
If you look carefully, you can see the lung outline in the middle of the right side of the chest. Big-time pneumothorax despite what looks like a perfectly placed tube. There are several possible explanations, and many of you sent me your guesses:
- The tube is in the lung. This rarely happens to normal lungs. Sure, you can probably do it to an ARDS lung, but otherwise it’s not likely.
- The tube is in the fissure. This does happen on occasion, but not often. And many times it works anyway.
- The tube is occluded or kinked. A PA or AP chest x-ray will show the kink, although bent tubes frequently work anyway. If a hemothorax is present, it is possible that a clot is plugging the tube. Clearing a plugged tube will be the subject of another post.
- It’s not really a chest tube. Hopefully, this would have been detected when it was placed, but it’s not always. The chest x-ray above looks great, right? Unfortunately, it’s a 2 dimensional representation of a 3-D object. Where is that tube in the z-axis?
In this case the correct answer is the last one. This is one time when I would actually recommend a lateral chest x-ray. Have a look at the result. You can clearly see the tube snaking around into the soft tissues of the back.
Bottom line: Remember that a perfect x-ray doesn’t necessarily mean a perfect tube. Go through the various possibilities quickly, and make it work.
A patient is transferred to your facility who had, as one of his problems, a sizable pneumothorax. A chest drain was placed at an outside facility prior to transfer. It is now 2 hours later, and as you finish evaluating him, you get the following x-ray.
What’s the problem here? How do you fix it? Tweet, email, or leave comments with your answers. Discussion and final answer on Friday!
More dogma, or is it actually useful? Any time a chest tube (tube thoracostomy) is inserted, we automatically order a chest x-ray. Even the ATLS course recommends obtaining an image after placement. But anything we do “automatically” is grounds for critical analysis to see if there is a valid reason for doing it.
A South African group looked at the utility of this practice retrospectively in 1004 of their patients. They place 1042 tubes. Here are the factoids:
- Patients were included if they had at least one chest x-ray obtained after insertion
- Patients were grouped as follows: Group A (10%) had the tube inserted on clinical grounds with no pre-insertion x-ray (e.g. tension pneumothorax). Group B (19%) had a chest x-ray before and had ongoing clinical concerns after insertion. Group C (71%) had a chest-xray before and no ongoing concerns.
- 75% of injuries were penetrating (75% stab, 25% GSW), 25% were blunt
- Group A (insertion with pre-x-ray): 9% had post-insertion findings that prompted a management change (kinked, not inserted far enough)
- Group B (ongoing clinical concerns): 58% required a management change based on the post-x-ray. 33% were subcutaneous or not inserted far enough (!!)
- Group C (no ongoing clinical concerns): 32 of 710 (5%) required a management change, usually because the tube was too deep
The authors concluded that if there are no clinical concerns (tube functioning, no clinical symptoms) after insertion, then a chest x-ray is not necessary.
Bottom line: But I disagree with the authors! Even with no obvious clinical concerns, the tube may not be functioning for a variety of reasons. Hopefully, this fact would then be discovered the next day when another x-ray is obtained. But this delays the usual progression toward removing the tube promptly by at least one day. It increases hospital stay, as well as the likelihood of infection or other hospital-associated complication. A chest x-ray is cheap compared to a day in the hospital, which would potentially happen in 5% of these patients. I recommend that we continue to obtain a simple one-view chest x-ray after tube insertion.
Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion.
It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.
The authors found that:
- The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
- Platelet count was very low in chest tube blood
- Potassium was higher (4.9 mmol/L), but not dangerously so
- INR, PTT, TT, Factor V and fibrinogen were unmeasurable
Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!
Related post: Chest tubes and autotransfusion
Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.