Complications following thoracic trauma managed with tube thoracostomy
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.
References (19)
- et al.
Predicting outcome after multiple trauma: which scoring system
Injury Int J Care Injured
(2004) - et al.
Delayed pneumothorax complicating minor rib fracture after chest trauma
Am J Emerg Med
(2008) - et al.
Complications of tube thoracostomy for acute trauma
Am J Surg
(1980) - et al.
Chest tube removal: end-inspiration or end-expiration?
J Trauma
(2001) - et al.
Complication rates of tube thoracostomy
Am J Emerg Med
(1997) - et al.
Application of abbreviated injury scale and injury severity score to 115 thoracic trauma cases—a retrospective study
J Med Sci
(1991) Morbidity of percutaneous tube thoracostomy in trauma patients
Eur J Cardiothorac Surg
(2002)- et al.
Tube thoracostomy: factors related to complications
Arch Surg
(1995) - et al.
Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy
J Trauma
(1989)
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