Not a new paper to cite here, just a collection of resources that refer to open thoracostomy in trauma.
A longstanding practice by some European and Australasian HEMS physicians, open thoracostomy is essentially a chest tube procedure without the actual intercostal catheter: the surgical incision is made, blunt dissection is performed, and the pleura penetrated. The wound is then left open.
This is a rapid way of decompressing a tension pneumothorax in a critically injured trauma patient who is intubated. The positive pressure ventilation prevents the thoracostomy wound from acting as an open, ‘sucking’, chest wound.
In many pre-hospital services this is the preferred approach to pleural decompression in an intubated patient, and also forms part of the approach to resuscitation in traumatic cardiac arrest.
Some principles to consider are:
A tube and drainage system are not necessary for the drainage of air, but should be used if there is signficant haemothorax
The tissues may re-appose during transport so physiological deterioration should prompt a re-fingering of the thoracostomy to re-establish the drainage tract and allow air to escape
Standard intravenous cannula devices may be shorter than the distance from chest wall to pleural space in many adults, adding to the inadequacy of needle decompression
Signs of tension pneumothorax are rarely if ever as obvious as the textbooks suggest – unexplained shock or hypoxaemia in a patient with actual or probably thoracic trauma should prompt consideration of pleural decompression even in the absence of obvious clinical signs of pneumothorax – subtle evidence only may exist, such as palpable subcutaneous emphysema
This should only be done in intubated patients undergoing positive pressure ventilation!
This video shows the procedure, done by a relative beginner; a slightly larger incision with more assertive dissection would make it faster and more effective
Intercostal catheters can kink, obstruct, or get pulled out. These hazards are greater during transport of the patient. Critical care and retrieval medicine doctors in Queensland, Australia (where many people are having a bad time right now) have invented an elegant alternative: using a cuffed tracheal tube in the pleural space instead. It can be attached to a Heimlich valve.
They even used a bit of science to demonstrate its effectiveness, by creating pneumothoraces and haemothoraces in sheep and comparing the tracheal tube with a standard intercostal catheter (ICC).
The method for insertion is simple:
Breach the pleura
Insert a 14 Fr Cook intubating bougie into the thoracic cavity
Railroad a 7.0 mm internal diameter tracheal tube (ETT) into the chest cavity
Inflate the cuff
Retract the tube until resistance is felt.
Remove the ETT connector
Attach a Heimlich valve
The results of the comparison are convincing: ‘The ETT proved faster to insert for both sheep. This was likely because it did not require suturing. Both the ETT and the ICC were comparable in draining blood. It was noted that neither tube was particularly effective when the haemothorax was positioned ‘side-up’. When turned ‘side-down’, both tubes successfully drained blood. Despite having multiple drainage ports, the ICC required more manipulation and was noted to kink. Conversely, the ETT with a single lumen and a Murphy eye, was stiffer and drained a similar amount of blood without the catheter having to be milked.’
Proposed advantages of this method include:
More portable equipment
Faster insertion
Provides kit redundancy
Does not require suturing
Avoids operator trauma from any sharp edges such as a fractured rib. (No attempt was made to place a finger into the chest cavity in the ETT group).
Allows for a smaller incision
Less trauma to the insertion site
Might also offer a back up, when conventional equipment has been exhausted.
The authors graciously note that both Portex and Cook have developed ICC kits that now go some way in supporting the original idea behind this study. These include flexible introducers (Portex) and guidewire insertion technique (Cook). Appraisal of the endotracheal tube as an alternative to the intercostal catheter Emerg Med Australas. 2010 Dec;22(6):573-4
Chest x-rays often miss pneumothoraces in the trauma room. These are occult pneumothoraces. A study using agreement by two fellowship trained radiologists as the gold standard for CXR interpretation showed that 80% of these were truly occult, ie. not detectable by the radiologists from CXR and only demonstrable on CT. Of those seven cases that could or should have been identified by emergency physicians (ie. ‘missed’ pneumothoraces) subcutaneous emphysema (5), pleural line (3), and deep sulcus sign (2) were detected by the radiologist reviewers.
This serves both as a reminder of the signs to look for on CXR for pneumothorax, and of the inadequacy of plain radiography in trauma patients. The authors advise in their discussion that ‘Thoracic ultrasonography may be the ideal diagnostic modality as it has a high sensitivity for the detection of PTX and it may be performed quickly at the bedside while maintaining spinal precautions’.
If you don’t know how to detect a pneumothorax with ultrasound yet, have a look here. Occult Pneumothoraces Truly Occult or Simply Missed: Redux J Trauma. 2010 Dec;69(6):1335-7
The old idea of three-sided taping of an occlusive dressing to treat open / sucking chest wounds has been replaced with just closing the hole with an occlusive dressing and treating any tension pneumothorax. If you don’t have an alternative then you can use an adhesive defibrillator pad to achieve this. Tactical Combat Casualty Care
Military doctors in Afghanistan reviewed their experience of thoracotomy done within 24 hours of admission to their hospital. The ballistic nature of thoracic penetrating trauma (mainly Afghan civilians without body armour) differs from the typical knife-wound related injury seen in survivors of thoracotomy reported in the pre-hospital literature.
Six of the patients presented in cardiac arrest – four PEA and two asystole. One of the PEA patients survived; this patient had sustained a thoracoabdominal GSW and had arrested 8 minutes from hospital. Following emergency thoracotomy, aortic control, and concomitant massive transfusion, return of spontaneous circulation (ROSC) was achieved and damage control surgery undertaken in both chest and abdomen.
The two patients in asystole had sustained substantial pulmonary and hilar injuries, and ROSC was never achieved. The patients in PEA all had arrested as a consequence of hypovolaemia from solid intra-abdominal visceral haemorrhage. All patients in PEA had ROSC achieved, albeit temporarily.
Following thoracotomy, patients required surgical manoeuvres such as pulmonary hilar clamping, packing and temporary aortic occlusion; hypovolaemia was the leading underlying cause of the cardiac arrest. These factors lead the authors to conclude that although isolated cardiac wounds do feature in war, they are unusual and the injury pattern of casualties in conflict zones are often complex and multifactorial. Is pre-hospital thoracotomy necessary in the military environment? Injury. 2010 Jul;41(7):1008-12
ICU patients with thoracic trauma who had no other indication for intubation than marked hypoxaemia (pO2/FiO2 < 200 mmHg) were randomised to intubation vs non-invasive ventilation (NIV). Analgesia was via epidural bupivacaine / fentanyl or iv remifentanil. Numbers are small (total 50 patients) - partly because the trial was stopped early due to large difference in the outcome of tracheal intubation between the two groups favouring NIV. Length of hospital stay was significantly shorter in the NIV group but there was no survival difference.
Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial Chest. 2010 Jan;137(1):74-80
The UK National Health Service’s National Patient Safety Agency published a report entitled ‘Risks of chest drain insertion’, reporting 12 deaths and 15 cases of serious harm related to chest drain insertion over a three year period. They issue the following recommendations under the title ‘For IMMEDIATE ACTION by the NHS and independent sector – Deadline for ACTION COMPLETE is 17 November 2008’:
Clinical governance leads in local organisations should audit current practice and develop local policies to ensure:
Chest drains are only inserted by staff with relevant competencies and adequate supervision
Ultrasound guidance is strongly advised when inserting a drain for fluid
Clinical guidelines are followed and staff made aware of the risks
Identify a lead for training of all staff involved in chest drain insertion
Written evidence of consent is obtained from patients before the procedure, wherever possible
Local incident data relating to chest drains is reviewed and staff encouraged to report further incidents
This is one of those ‘wow they really do that!?‘ papers…Patients undergoing thoracotomy and aortic clamping for pre-hospital blunt traumatic arrest either in the field or in the ED were evaluated for the outcome of survival to ICU admission. None of the 81 patients who underwent this intervention survived to discharge.
Field thoracotomy resulted in shorter times from arrival of the emergency medical team to performance of the thoracotomy (19.2 vs 30.7 mins). Patients who arrested in front of the team had a greater ICU admission rate than those who were already in cardiac arrest when the team arrived (70% vs 8%).
One may argue against an intervention that seems to have resulted in no benefit to the patient. However a counterargument might be that an ICU admission allows for better end-of-life management for grieving families, and for the possibility of organ donation.
Interestingly, there were some neurologically intact survivors of emergency thoracotomy for blunt trauma by this service, although they were excluded from the study for either (i) receiving the field thoracotomy before full arrest or (ii) arresting after arrival in the ED. Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system Resuscitation. 2009 Nov;80(11):1270-4
37 patients with blunt traumatic cardiac arrest underwent attempted resuscitation by a HEMS crew over a four year period. Chest decompression was performed in 18 cases (17 thoracostomy, one needle decompression). The procedure revealed evidence of chest injury in 10 cases (pneumothorax, haemothorax, massive air leak) and resulted in return of circulation and survival to hospital in four cases. All four cases died of associated major head injury, although one became a heart beating organ donor. Only half of the cases found to have pneumothorax demonstrated clinical signs of one prior to chest decompression.
The authors state: ‘Relying on clinical signs of the thorax alone will not identify all patients with these injuries, and our data support extending the practice into all patients with a suitable mechanism of injury together with external evidence of chest injury.’ Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest Emerg Med J. 2009 Oct;26(10):738-40
This CT study of 110 trauma patients showed: ‘the standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7–59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration’. Consistent with several other Ultrasound and CT-based studies published on the same subject then. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7
