Intercostal catheter insertion: are we really doing well?

Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.
ANZ Journal of Surgery (Impact Factor: 1.5). 05/2012; 82(6):392-4. DOI: 10.1111/j.1445-2197.2012.06093.x
Source: PubMed

ABSTRACT   Intercostal catheters (ICC) are the standard management of chest trauma, but are associated with complications in up to 30%. The aim of this study was to evaluate errors in technique during ICC insertion to characterize the potential benefit of improved training programmes.
  Prospective audit of all ICC in trauma patients at a level 1 trauma centre for over 12 months. Exclusions were pigtail catheters and ICC inserted during thoracic surgery. Errors were identified from patient examination and chest imaging; they were defined as insertional, positional, incorrect size (<28 French) and lack of antibiotic prophylaxis. Ongoing complications unrelated to an error in technique, for example blocked tube, were not analysed.
  Fifty-seven patients received a total of 94 ICC during the study period. Patients were predominantly male (77%), mean age of 40 ± 20 years, mean injury severity score 27 ± 13, mean abbreviated injury scale chest 3.8 ± 0.72. 86% were blunt trauma and 14% penetrating chest injuries. Thirty-six errors in technique occurred in 33 ICC insertions (38%). The most common errors were absence of prophylactic antibiotics (13%), ICC too far out (9%), kinked (6%) and wrong-sized ICC (5%). Emergency had a significantly greater frequency of errors than other specialties (67%, relative risk 2.11, P= 0.002). The majority of ICC were inserted by registrars, and registrars made a greater number of errors than fellows or consultants (relative risk 2.00, P= 0.02).
  This study identified a large number of preventable errors for ICC insertion in trauma patients. Standardized institutional credentialing systems may be required to ensure adequate proficiency of trainees performing this procedure.

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    ABSTRACT: Abstract Objective The selective conservative management of small pneumothoraces (PTXs) following stab injuries is controversial. We reviewed a cohort of patients managed conservatively in a high volume trauma service in South Africa. Materials and methods A retrospective review over a 2-year period identified 125 asymptomatic patients with small PTXs measuring <2 cm on chest radiograph who were managed conservatively. Results Of the 125 patients included in the study, 92 % were male (115/125), and the median age for all patients was 21 years (19–24). Ninety-seven per cent (121/125) of the weapons involved were knives, and 3 % (4/125) were screwdrivers. Sixty-one per cent of all injuries were on the left side. Eighty-two per cent (102/125) sustained a single stab, and 18 % (23/125) had multiple stabs. Thirty-nine per cent (49/125) had a PTX <0.5 cm (Group A), 26 % (32/125) were ≥0.5 to <1 cm (Group B), 19 % (24/125) were ≥1 to <1.5 cm (Group C) and 15 % (20/125) were ≥1.5 to <2 cm (Group D). Three per cent of all patients (4/125) eventually required ICDs (one in Group C, three in Group D). All four patients had ICDs in situ for 24 h. The remaining 97 % (121/125) were all managed successfully by active clinical observation alone. There were no subsequent readmissions, morbidity or mortality as a direct result of our conservative approach. Conclusions The selective conservative management of asymptomatic small PTXs from stab injuries is safe if undertaken in the appropriate setting.
    European Journal of Trauma and Emergency Surgery 06/2014; · 0.26 Impact Factor
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    ABSTRACT: Introduction: Routine chest radiography (CXR) following tube thoracostomy (TT) is a standard practice in most trauma centres worldwide. Evidence supporting this routine practice is lacking and the actual yield is unknown. Materials and methods: We performed a retrospective review of 1042 patients over a 4-year period who had a routine post-insertion CXR performed in accordance with current ATLS1 recommendations. Results: A total 1042 TTs were performed on 1004 patients. Ninety-one per cent of patients (913/1004) were males, and the median age for all patients was 24 years. Seventy-five per cent of all injuries (756/ 1004) were from penetrating trauma, and the remaining 25% (248/1004) were from blunt. The initial pathologies requiring TT were: haemopneumothorax: 34% (339/1042), haemothroax: 31% (314/1042), simple pneumothorax: 25% (256/1042), tension pneumothorax: 8% (77/1042) and open pneumothorax: 5% (54/1042). One hundred and three patients had TTs performed on clinical grounds alone without a pre-insertion CXR [Group A]. One hundred and ninety-one patients had a pre-insertion CXR but had persistent clinical concerns following insertion [Group B]. Seven hundred and ten patients had pre- insertion CXR but no clinical concerns following insertion [Group C]. Overall, 15% (152/1004) [9 from Group A, 111 from Group B and 32 from Group C] of all patients had their clinical management influenced as a direct result of the post-insertion CXR. Conclusions: Despite the widely accepted practice of routine CXR following tube thoracostomy, the yield is relatively low. In many cases, good clinical examination post tube insertion will provide warnings as to whether problems are likely to result. However, in the more rural setting, and in resource challenged environments, there is a relatively high yield from the CXR, which alters management. Further prospective studies are needed to establish or refute the role of the existing ATLS1 guidelines in these specific environments.
    Injury 01/2014; · 2.46 Impact Factor
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    American Journal of Respiratory and Critical Care Medicine 05/2014; 189(10):e64-5. · 11.04 Impact Factor


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May 29, 2014