Prehospital thoracostomy tube misplacement

An interesting study from Germany examined prehospital thoracostomy tube (TT) placement by physicians working in the field. Of 69 patients who received them, 67 underwent prehospital intubation. 88 TT were placed in the 69 patients.
There were 19/88 (22%) radiologic chest tube misplacements (defined as too far in the chest, twisted, or bent). The position of 10/88 (11%) chest tubes had to be corrected. None of the patients with a TT had a “not-decompressed” pneumothorax or a chest tube placed below the diaphragm or into a solid organ.
Roughly half were placed in the ‘Monaldi’ position (the second or third intercostal space in the midclavicular line)…..

Monaldi position

…..and half in the Bülau position (fourth or fifth intercostal space in the midaxillary line).
Bülau position

There was no difference in the misplacement rates between the two positions although interestingly helicopter doctors (as opposed to ground response) more often opted for the Monaldi position.
It is not possible to tell from the results whether the TT insertion was indicated in all cases. Also, it would be interesting to know whether TT insertion preceded or followed tracheal intubation. While it is heartening that these physicians do not routinely rely on needle decompression, I cannot fathom while simple open thoracostomy was not used, avoiding the risk of tube misplacement and saving time.
See this post for a more thorough review of open thoracostomy and the limitations of needle decompression.

Objectives. To evaluate the frequency of use, placement site, success and misplacement rates, and need for intervention for tube thoracostomies (TTs), and the complications with endotracheal intubation associated with TT in the prehospital setting.

Methods. We performed a five-year, retrospective study using the records of 1,065 patients who were admitted to the trauma emergency room at a university hospital and who had received chest radiographs or computed tomography (CT) scans within 30 minutes after admission.

Results. Seven percent of all patients received a TT (5% unilateral, 2% bilateral). Ninety-seven percent of all patients with a TT were endotracheally intubated. The success rate for correctly placed chest tubes was 78%. Twenty-two percent of the chest tubes were misplaced (i.e., too far in the chest, twisted, or bent); half of those had to be corrected, with one needing to be replaced. There were no statistical differences in the frequency of Monaldi or Bülau positions, or the frequency of left or right chest TT. In addition, the two positions did not differ in misplacement rates or the need for intervention. Helicopter emergency medical services physicians used the Monaldi position significantly more frequently than the Bülau position. In-hospital physicians performing interhospital transfer used the Bülau position significantly more frequently, whereas ground emergency medical physicians had a more balanced relationship between the two positions. Tube thoracostomy had no influence on endotracheal tube misplacement rates, and vice versa.

Conclusion. Tube thoracostomy positioning mostly depends on the discretion of the physician on scene. The Monaldi and Bülau positions do not differ in misplacement or complication rates.

Incidence And Outcome Of Tube Thoracostomy Positioning In Trauma Patients
Prehosp Emerg Care. 2011 Oct 3. [Epub ahead of print]

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