Elsevier

Injury

Volume 43, Issue 1, January 2012, Pages 46-50
Injury

Complications following thoracic trauma managed with tube thoracostomy

https://doi.org/10.1016/j.injury.2011.06.420Get rights and content

Abstract

Introduction

Tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma.

Methods

A retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007–12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann–Whitney test, and multivariate analysis.

Results

154 patients were included with 22.1% (n = 34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p = 0.02 and p < 0.001), increased chest AIS (p = 0.01), and the presence of an extrathoracic injury (p = 0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p = 0.03) was a significantly independent predictor of CTCs.

Conclusions

CTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.

Introduction

Chest tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although potentially life-saving, this relatively simple procedure is associated with a reported complication rate as high as 25%.10 Chest tube related complications, such as recurrent pneumothorax, retained haemothorax, and empyema, frequently require additional invasive procedures ranging from the reinsertion of a new chest tube to video assisted thoracoscopic surgery or thoracotomy.18

Chest tube complications may be operator-dependent and increased rates have been associated with improper insertion technique, decreased operator experience, and increased clinical urgency.6, 7 In a retrospective review of 379 trauma patients requiring 599 chest tubes, Etoch et al. reported a complication rate of 21% and suggested training plays a significant role. In this study, chest tube complication rates varied significantly from 13% for emergency room physicians to 6% for surgeons (p < 0.001), but did not differ based on location of placement (i.e. emergency department vs. the operating room).6 A standardized approach to initial chest tube insertion and subsequent removal that includes appropriate training and supervision may decrease the potential impact of operator-dependant variables.1, 6

Clinical variables that contribute to the development of chest tube complications are less well-defined and more difficult to modify. Mechanism of injury, especially contaminating injury or incomplete drainage of the pleural space, plays an important role in the subsequent development of complications. Polytrauma, prolonged time in the ICU, increased duration of mechanical ventilation, and significant lung contusion are risk factors for complications associated with blunt trauma.6, 7 Penetrating chest injuries, especially those with large volume haemothorax and freely communicating pneumothorax with continuous air leak, on the other hand, may also increase the risk of chest tube complications.7

Although the current literature is inconclusive, clinical management guidelines that specifically address differences in injury patterns and other risk factors may mitigate many of the complications associated with chest tubes in trauma patients.12 This study investigates the incidence of and risk factors associated with the development of chest tube complications following thoracic trauma.

Section snippets

Methods

A retrospective review of all trauma patients admitted to a level I trauma centre between January 1, 2007 and December 31, 2007 was conducted in accordance with the ethical standards and approval of the University of Pennsylvania's Institutional Review Board. Inclusion criteria included age greater than or equal to 16 years and the need for chest tube placement for injuries resulting in pneumothorax, haemothorax, or pneumohaemothorax within the first 24 h of admission. Chest tube insertions for

Results

Between January 1, 2007 and December 31, 2007, a total of 227 patients with traumatic chest injuries requiring chest tube insertion within 24 h were admitted to the Hospital of the University of Pennsylvania. On review of the clinical records, 62 patients were excluded due to death prior to completion of therapy and 11 were excluded because of non-traumatic causes of pneumothorax or haemothorax (n = 9) accidental removal by the patient (2). Demographics for the study cohort (n = 154) are listed in

Discussion

Chest tube insertion is the most common definitive management strategy used to treat serious thoracic trauma. In this retrospective review, we found a high percentage of chest tube complications following initial insertion with over 20% of patients requiring an additional intervention. The need for chest tube reinsertion for recurrent pneumothorax was surprising and accounted for 82.5% of CTCs. Recurrent pneumothorax following chest tube removal occurred in 56 patients with nearly half of these

Conflict of interest statement

None.

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