Chest Tubes in the Trauma Bay

(A Review on Chest Tubes in the Trauma Patient )

Indications for Chest Tube Placement in Trauma Patients

• Pneumothorax (simple, tension)
• Hemothorax
• Esophageal rupture with gastric leak into pleural space
• Traumatic arrest (bilateral chest tubes)

Quick Caveat:

Detecting a traumatic pneumothorax in blunt chest trauma: Ultrasound vs Supine AP CXR- ULTRASOUND IS BETTER!!! Please perform EFAST instead of standard FAST!!!!! (See last trauma drama post)

Contraindications for Chest Tube Placement in Trauma Patients

Although there are no published guidelines that state absolute contraindications for chest tube placement, some argue that the need for emergent thoracotomy is an absolute contraindication for chest tube placement in trauma patients.  Relative contraindications include adherent pleura (previous infections, scar tissue, s/p pleurodesis), current infection over site of chest tube placement or bleeding diathesis (high INR, low platelets, hemophelia).

How to Properly Place A Chest Tube

Here I will refer you to a wonderful video on chest tube insertion (see below).

NEJM clinical video of chest tube insertion:

http://www.nejm.org/doi/full/10.1056/NEJMvcm071974

Remember, you should NEVER compromise universal precautions in an urgent trauma situation… just gown and glove up faster.   Aseptic technique protects the patient against infectious complications of chest tube placement that may prolong their hospital stay and may increase mortality significantly.

Some tips:

–       Consent patient or next of kin only if time permits

–       Selection of size:

• 16-22Fr in stable pneumothorax
• 24-48Fr in unstable pneumothorax or if patient is on/will be on mechanical ventilation

–       Remember to obtain post-procedure CXR, but keep in mind CT is best for position placement

Complications of Chest Tube Placement

The complication rate of tube thoracostomies are estimated at 2-10%.

–       Acute

• Malposition of chest tube:
  • intraparenchymal placement (most often in preexisting pulmonary disease)
  • interlobar fissural tube placement
  • placement into chest wall (in cases of flail chest, rib fractures)
  •  mediastinal tube placement (going too far in)
  • abdominal placement (placed “too low” or unidentified diaphragmatic hernia)
• Blockage of the tube from kinking, lung debris, blood clots, etc. (suspect it if the pt coughs and fluid within the drain does not fluctuate)
• Bleeding: potential vessel injuries include intercostal vessels, if mediastinum is penetrated- large vessel injury
• Pain from placement
• Re-expansion pulmonary edema (seen more commonly with re-expansion of lung with chronic lung collapse, not acute)
• Displacement of tube (usually from improper anchoring of chest tube- suggested techniques include horizontal mattress suture with stay ties around the chest tube)

–       Late

• Infections
• Subcutaneous emphysema
• Blockage of chest tube
• Air leak
• Dislocation of chest tube
• Fistula formation- bronchocutaneous fistula, pleurocutaneous fistula, AV fistula between subcutaneous chest wall vein and intercostal artery
• Nerve injury
• Post extubation pneumothorax

Prophylactic Antibiotic use?

In the 1990s, there were two studies published that found that prophylactic antibiotics in patients undergoing tube thoracostomy significantly lowered the infection rate.  However, these studies were later debunked due to poor methodology.   It is a controversial topic.  Later studies showed that there was no significant difference in infection rates when prophylactic antibiotics were given. There is insufficient evidence to support prophylactic antibiotics in all patients requiring chest tube insertion, although it may be appropriate in pts at high risk for developing infectious complications such as seen with penetrating chest trauma. Level III evidence suggests giving a 2^nd generation cephalosporin for 24 hrs may reduce risk of pneumonia.

References

Kesieme, E., et al. Tube Thoracostomy: Complications and its Management. Pulmonary Medicine. Volume 2012. Article ID 256878.

Luchette, F., et al. Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemopneumothorax: east practice management guidelines work group. 2012.

www.trauma.org. Chest Trauma: Intercostal Chest Drains. March 2004. Accessed November 2012.

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