Respiration / Breathing Management

#### CHEST TRAUMA (GENERAL)

Curr Opin Anaesthesiol. 2019 Apr;32(2):227-233

# Thoracic trauma in military settings: a review of current practices and recommendations.

Mansky R, Scher C.

PURPOSE OF REVIEW: To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population.

RECENT FINDINGS: Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters.

SUMMARY: The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.

J Thorac Dis. 2019 Feb;11(Suppl 2):S186-S191

# Chest drain and thoracotomy for chest trauma.

Bertoglio P, Guerrera F, Viti A, Terzi A, Ruffini E, Lyberis P, Filosso P

Traumas are the leading cause of death in the first four decades of life. Nevertheless, thoracic traumas only seldom require invasive procedures. In particular, chest drain placement is required in case of pleural disruption causing haemothorax, pneumothorax or haemopneumothorax. Although large-bore chest drains have been traditionally used in case of haemothorax, recent evidences seem to question this routine, showing good performances of small-bore and pig tail drains. Although it is a common procedures, experience and training is needed to avoid complications which might be even lethal. Surgical exploration after thoracic trauma is rare, accounting for less than 3% of traumas. Penetrating traumas more likely require surgical exploration compared to blunt trauma. Anterolateral thoracotomy is usually performed in this setting, but also clamshell or hemi-clamshell approach can be used. In selected patients, minimally invasive techniques can be performed. Large randomized trials are still needed to assess and standardized the role of new tools and procedures in the thoracic trauma setting.

Case Rep Emerg Med. 2019 Jul 2;2019:2895439

# A Case of an Advanced Chain of Survival in Penetrating Cardiac Injury.

Andersen M, De Paoli F, Mærkedahl R, Jepsen S, Dalgaard K, Falstie T, Gerstrøm G

The survival rate of penetrating cardiac trauma is dismal, with only a few patients reaching the hospital with any signs of life. Short transport time and close proximity to the trauma center are positive factors for survival. We report the successful case of a 21-year-old male with penetrating cardiac injury and tension-pneumothorax with long distance to a trauma facility. The patient was stabbed twice in the anterior left side of the thorax. The emergency services found the patient with suspicion of left tension-pneumothorax. Urgent left mini-thoracotomy was established resulting in spontaneous respiration and clinical improvement. Due to rapid clinical deterioration and clinical suspicion of pericardial tamponade, patient was transported to the local regional hospital only minutes away. Echocardiography confirmed tamponade, and urgent ultrasound-guided pericardiocentesis was performed. During the transport blood was intermittently drained from the pericardial sack until arrival at the trauma center where a penetrating injury to the left ventricle was repaired during urgent cardiac surgery. The patient was discharged 8 days after the incident.

Conclusion. Well organized emergency medical transport systems increase the chance of survival in penetrating cardiac injuries. Urgent pericardiocentesis with continuous drainage can help stabilize a patient until arrival at trauma facility.

Ann Med Surg (Lond). 2019 May 25;43:25-28

# Bilateral thoracic trauma; presentation and management, a case series.

Baram A, Kakamad F

Introduction: Unilateral chest trauma has been perfectly described in the literature while bilateral chest trauma has never been specifically probed, the aim of this study is to highlight the specificities, presentations, the difference in the therapeutic algorithm and outcome of patients with bilateral thoracic trauma.

Patients and methods: A single center, prospective study was carried out in four years. The data were taken directly from the patients, patient's relatives and the medical records. All patients presenting with bilateral chest trauma, admitted to the hospital overnight, were included in this study. The patients were managed according to the Advanced Trauma Life Support (ATLS) protocol which consists of primary and secondary surveys. For those patients who diagnosed to have either haemo or pneumothorax or both, thoracostomy tube was inserted. Descriptive and analytical analyses were calculated.

Results: The study included 107 patients. Bilateral blunt trauma was found in 72 (67.3%) cases while bilateral penetrating trauma was found in 35 (32.7%) patients. The most common mechanism of trauma was road traffic accidents (RTA) accounting for 68 (63.6%) victims. Overall 30-day mortality was 14.9%. In blunt trauma, 3 or more rib fracture, pulmonary contusion, intubation, and intensive care unit admission were among the predictors of increased risk of mortality.

Conclusion: Bilateral thoracic trauma has comparable patterns of presentation, choices of investigation, strategies of management, predictors of the outcome, morbidity and mortality with unilateral chest trauma.

J Trauma Acute Care Surg. 2019 Aug;87(2):371-378

# Predictors of postinjury acute respiratory distress syndrome: Lung injury persists in the era of hemostatic resuscitation.

Kornblith L, Robles A, Conroy A, Redick B, Howard B, Hendrickson C, Moore S, Nelson M, Moazed F, Callcut R, Calfee C, Cohen M

BACKGROUND: Acute respiratory distress syndrome (ARDS) following trauma is historically associated with crystalloid and blood product exposure. Advances in resuscitation have occurred over the last decade, but their impact on ARDS is unknown. We sought to investigate predictors of postinjury ARDS in the era of hemostatic resuscitation.

METHODS: Data were prospectively collected from arrival to 28 days for 914 highest-level trauma activations who required intubation and survived more than 6 hours from 2005 to 2016 at a Level I trauma center. Patients with ratio of partial pressure of oxygen to fraction of inspired oxygen of 300 mmHg or less during the first 8 days were identified. Two blinded expert clinicians adjudicated all chest radiographs for bilateral infiltrates in the first 8 days. Those with left-sided heart failure detected were excluded. Multivariate logistic regression was used to define predictors of ARDS.

RESULTS: Of the 914 intubated patients, 63% had a ratio of partial pressure of oxygen to fraction of inspired oxygen of 300 or less, and 22% developed ARDS; among the ARDS cases, 57% were diagnosed early (in the first 24 hours), and 43% later. Patients with ARDS diagnosed later were more severely injured (ISS 32 vs. 20, p = 0.001), with higher rates of blunt injury (84% vs. 72%, p = 0.008), chest injury (58% vs. 36%, p < 0.001), and traumatic brain injury (72% vs. 48%, p < 0.001) compared with the no ARDS group. In multivariate analysis, head/chest Abbreviated Injury Score scores, crystalloid from 0 to 6 hours, and platelet transfusion from 0 to 6 hours and 7 to 24 hours were independent predictors of ARDS developing after 24 hours.

CONCLUSIONS: Blood and plasma transfusion were not independently associated with ARDS. However, platelet transfusion was a significant independent risk factor. The role of platelets warrants further investigation but may be mechanistically explained by lung injury models of pulmonary platelet sequestration with peripheral thrombocytopenia.

LEVEL OF EVIDENCE: Prognostic study, level IV.

Eur J Trauma Emerg Surg. 2019 Jul 19;Epub ahead of print

# Predictors of mortality in patients with rib fractures.

Marini C, Petrone P, Soto-Sánchez A, García-Santos E, Stoller C, Verde J

BACKGROUND: The aim of this study was to identify risk factors for morbidity and mortality in patients with rib fractures with focus on identifying a more exact age-dependent cut-off for increased morbidity and mortality.

METHODS: Retrospective study of patients 16 years or older with rib fractures from blunt trauma.

EXCLUSION CRITERIA: patients undergoing rib plating. Initial chest X-ray and Computed Tomography (CT) scans were re-read for the number of rib fractures (NRF) and presence of pulmonary contusion (PC). Data included demographics, mechanism of injury (MOI), NRF, associated injuries, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), Geriatric Trauma Outcome Score (GTOS), presence of pneumothorax, hemothorax, hemo-pneumothorax, PC, Adult Respiratory Distress Syndrome (ARDS), pulmonary complications (ventilator-associated pneumonia, nosocomial pneumonia), and mortality. PC was quantified from CT scans with Mimics. Continuous data were analyzed using Student's t test. Variables significantly different by univariate analysis were analyzed by logistic regression analysis.

RESULTS: The study group consisted of 1188 adult trauma patients admitted during a 2-year period; 800 males and 388 females, with a mean age of 54 ± 21. MOI: MVC, 735 (61.8%); falls, 364 (30.6%); other: 89. Mean NRF, 4 ± 2; GCS, GTOS, and ISS, 15 (15-15), 101 (82-124), and 19 ± 9, respectively. Incidence of PC was 329 (27.7%); PTX, HTX, and HTX/PTX, 264 (20.2%), 57 (4.8%), and 147 (12.4%). Flail chest, in 17 (1.4%); 321 required mechanical ventilation. Age, GCS, male gender, and ISS but not NRF and/or PC were predictive of mortality.

CONCLUSIONS: Increased mortality in patients with rib fractures starts at 65 years of age without a further increase until age ≥ 80. NRF does not predict increased mortality independent of age. Severe TBI is the most common cause of death in patients 16-75 years, as opposed to respiratory complications in patients 80 years-old or greater.

Emerg Med J. 2019 Oct;36(10):608-612

# Pulmonary embolism following complex trauma: UK MTC observational study.

Glover T, Sumpter J, Ercole A, Newcombe V, Lavinio A, Carrothers A, Menon D, O'Leary R

OBJECTIVES: To describe the incidence of pulmonary embolism (PE) in a critically ill UK major trauma centre (MTC) patient cohort.

METHODS: A retrospective, multidataset descriptive study of all trauma patients requiring admission to level 2 or 3 care in the East of England MTC from 1 November 2014 to 1 May 2017. Data describing demographics, the nature and extent of injuries, process of care, timing of PE prophylaxis, tranexamic acid (TXA) administration and CT scanner type were extracted from the Trauma Audit and Research Network database and hospital electronic records. PE presentation was categorised as immediate (diagnosed on initial trauma scan), early (within 72 hours of admission but not present initially) and late (diagnosed after 72 hours).

RESULTS: Of the 2746 trauma patients, 1039 were identified as being admitted to level 2 or 3 care. Forty-eight patients (4.6%) were diagnosed with PE during admission with 14 immediate PEs (1.3%). Of 32.1% patients given TXA, 6.3% developed PE compared with 3.8% without TXA (p=0.08).

CONCLUSION: This is the largest study of the incidence of PE in UK MTC patients and describes the greatest number of immediate PEs in a civilian complex trauma population to date. Immediate PEs are a rare phenomenon whose clinical importance remains unclear. Tranexamic acid was not significantly associated with an increase in PE in this population following its introduction into the UK trauma care system.

#### NEEDLE DECOMPRESSION / TENSION PNEUMOTHORAX

Am J Emerg Med. 2019 Jan;37(1):173.e1-173.e2.

# Spontaneous pneumothorax resulting in tension physiology.

Kelly C, Carlberg M, Madsen T

Spontaneous pneumothorax (SP) is a relatively common pathology in emergency medicine; however, scant information is published regarding SPs developing tension physiology in the literature. Risk factors for spontaneous pneumothorax include smoking, family history, and underlying lung disease such as chronic obstructive lung disease (COPD), cystic fibrosis, tuberculosis, among others. Treatment often involves conservative management, needle aspiration, catheter placement, or tube thoracostomy. Tension pneumothorax, however, is a life threatening condition requiring emergent intervention. Case reports have demonstrated large SPs with midline shift but without tension physiology as patients largely remained hemodynamically stable. We report the case of an 18-year-old male presenting to the Emergency Department (ED) with a SP that rapidly developed tension physiology with mediastinal shift and hypotension resolved by needle decompression and CT placement.

J Spec Oper Med. Winter 2018;18(4):18-23.

# Larger-Caliber Alternative Devices for Decompression of Tension Hemopneumothorax in the Setting of Hemorrhagic Shock.

McEvoy CS, Leatherman ML, Held JM, Fluke LM, Ricca RL, Polk T.

BACKGROUND: The 14-gauge (14G) angiocatheter (AC) has an unacceptably high failure rate in treatment of tension pneumothorax (tPTX). Little is known regarding the interplay among hemorrhage, hemothorax (HTX), and tPTX. We hypothesized that increased hemorrhage predisposes tension physiology and that needle decompression fails more often with increased HTX.

METHODS: This is a planned secondary analysis of data from our recent comparison of 14G AC with 10-gauge (10G) AC, modified 14G Veress needle, and 3mm laparoscopic trocar conducted in a positive pressure ventilation tension hemopneumothorax model using anesthetized swine. Susceptibility to tension physiology was extrapolated from volume of carbon dioxide (CO2) instilled and time required to induce 50% reduction in cardiac output. Failures to rescue and recover were compared between the 10% and 20% estimated blood volume (EBV) HTX groups and across devices.

RESULTS: A total of 196 tension hemopneumothorax events were evaluated. No differences were noted in the volume of CO2 instilled nor time to tension physiology. HTX with 10% EBV had fewer failures compared with 20% HTX (7% versus 23%; p = .002). For larger-caliber devices, there was no difference between HTX groups, whereas smaller-caliber devices had more failures and longer time to rescue with increased HTX volume as well as increased variability in times to rescue in both HTX volume groups.

CONCLUSION: Increased HTX volume did not predispose tension physiology; however, smaller-caliber devices were associated with more failures and longer times to rescue in 20% HTX as compared with 10% HTX. Use of larger devices for decompression has benefit and further study with more profound hemorrhage and HTX and spontaneous breathing models is warranted.

Am J Emerg Med. 2019 Feb;37(2):377.e5-377.e6

# Left ventricular perforation with catheter decompression.

Shin-Kim J, Zapolsky N, Wan E, Steinberg E, Heller M, Jacoby J

Thoracostomy tube placement is one of the more common procedures performed in the Emergency Department, most commonly for treatment of pneumothorax or hemothorax but occasionally for drainage of empyema or pleural effusion. Thoracostomy may be a life-saving procedure with a wide range of complication rates reported, ranging from 19.4-37%, most commonly extrathoracic placement. Most recent meta-analyses showed a relatively stable complication rate of 19% over the past three decades with the vast majority being benign in nature. We present a case with the rare complication of thoracostomy in which of a small-caliber thoracostomy tube was placed in the left ventricle. Although thoracotomy was performed to remove the catheter, the patient remained virtually asymptomatic and had an uneventful course.

J Trauma Acute Care Surg. 2019 Mar 1;Epub ahead of print

# ThoraSite: A device to improve accuracy of lateral decompression needle and chest tube placement.

Shah A, Kothera C, Dheer S

BACKGROUND: Multiple reports have detailed an unacceptably high error rate in the siting of decompression needles and tubes and describe associated iatrogenic injuries. The objective of the current study was to measure the accuracy of the novel ThoraSite template for identifying an acceptable intercostal space (ICS) for lateral needle or tube thoracostomy.

METHODS: Two trained operators used the ThoraSite to place radiopaque needles in the left and right lateral chests of 12 cadavers. An independent radiologist reviewed fluoroscopy images to determine the primary outcome: the ICS in which each needle was placed. Secondary outcomes were ICS's palpable through ThoraSite's Safe Zone; needle placement relative to the anterior (AAL) and mid-axillary (MAL) lines; and percent correct placement (defined as the 3, 4, or 5 ICS from 1cm anterior to the AAL to 1cm posterior to the MAL).

RESULTS: The 6 female and 6 male cadavers spanned 4'11" (150cm) to 6'7" (201cm), 80lb (36kg) to 350lb (159kg), and 16 kg/m to 42 kg/m BMI. All 24 needles were placed in either the 3 (4/24 needles, 17%); 4 (10/24 needles, 42%); or 5 ICS (10/24 needles, 42%). In 10/24 assessments (42%), two ICS's were palpable in ThoraSite's Safe Zone. All palpable ICS's were either the 3 (8/34, 24%); 4 (15/34, 44%); or 5 ICS (11/34, 32%). 23/24 needles (96%) were inserted from 1cm anterior to the AAL to 1cm posterior to the MAL. 23/24 needle placements (96%) were correct.

CONCLUSIONS: ThoraSite use was associated with needle placement in the 3, 4, or 5 ICS in an area roughly spanning the AAL to MAL in anatomically diverse cadavers. By facilitating appropriate needle/tube placement, ThoraSite use may decrease iatrogenic injuries. Future study involving representative users may be useful to further evaluate ThoraSite accuracy.

LEVEL OF EVIDENCE: Level IV STUDY TYPE: Therapeutic and care management.

Int J Surg. 2019 Aug;68:85-90

# Can ultrasound be used as an adjunct for tube thoracostomy? A systematic review of potential application to reduce procedure-related complications.

Menegozzo C, Artifon E, Meyer-Pflug A, Rocha M, Utiyama E

BACKGROUND: chest tube insertions are commonly performed in various scenarios. Although frequent, these procedures result in a significant complication rate, especially in the acute care setting. Ultrasonography has been incorporated to interventional procedures aiming to reduce the incidence of complications. However, little is known about the applications of ultrasound in tube thoracostomies. The aim of this systematic review is to present the potential applications of ultrasonography as an adjunct to the procedure.

METHODS: we searched Medline/Pubmed, EMBASE and Scopus databases. Out of 3012 articles, we selected 19 for further analysis. Thirteen of those were excluded because they did not meet the inclusion criteria. Ultimately, 6 articles were thoroughly evaluated and included in the review.

RESULTS: The included articles show that ultrasound can be used to correctly identify a safe insertion site, to accurately find a vulnerable intercostal artery, and is reliable for timely diagnosis of drain malpositioning.

CONCLUSION: this systematic review highlights the potential benefits of incorporating ultrasonography in tube thoracostomies. No randomized clinical trials are available. However, it is reasonable to assume that proper use of ultrasound may reduce procedure-related complications.

J Surg Res. 2019 Jul 10;244:225-230

# Chest Tube Management Practices by Trauma Surgeons.

Parker M, Newcomb A, Liu C, Michetti C

BACKGROUND: Chest tube (CT) placement is among the most common procedures performed by trauma surgeons; evidence guiding CT management is limited and tends toward thoracic surgery patients. The study goal was to identify current CT management practices among trauma providers.

MATERIALS AND METHODS: We designed a Web-based multiple-choice survey to assess CT management practices of trauma providers who were active, senior, or provisional members (n = 1890) of the Eastern Association for the Surgery of Trauma and distributed via e-mail. Descriptive statistics were used.

RESULTS: The response rate was 39% (n = 734). Ninety-one percent of respondents were attending surgeons, the remainder fellows or residents. Regarding experience, 36% of respondents had five or fewer years of practice, 54% 10 y or fewer, and 79% 20 y or fewer. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with experience of <5 y were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CTs for hemothorax and unstable patients with PTX, and larger tubes for unstable patients with hemothorax. Most respondents (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice.

CONCLUSIONS: Trauma CT management is variable and nonstandardized, depending mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.

Mil Med. 2019 May 29 2019;Epub ahead of print

# Incidence of Hyperoxia in Combat Wounded in Iraq and Afghanistan: A Potential Opportunity for Oxygen Conservation.

Schauer S, April M, Naylor J, Mould-Millman N, Bebarta V, Becker T, Maddry J, Ginde A

INTRODUCTION: Oxygen supplementation is frequently used in critically injured trauma casualties in the combat setting. Oxygen supplies in the deployed setting are limited so excessive use of oxygen may unnecessarily consume this limited resource. We describe the incidence of supraphysiologic oxygenation (hyperoxia) within casualties in the Department of Defense Trauma Registry (DoDTR).

METHODS: This is a subanalysis of previously published data from the DoDTR – we isolated casualties with a documented arterial blood gas (ABG) and categorized hyperoxia as an arterial oxygen >100 mmHg and extreme hyperoxia > 300 mmHg (a subset of hyperoxia). We defined serious injuries as those with an Abbreviated Injury Score (AIS) of 3 or greater. We defined a probable moderate traumatic brain injury of those with an AIS of 3 or greater for the head region and at least one Glasgow Coma Scale at 8 or less.

RESULTS: Our initial search yielded 28,222 casualties, of which 10,969 had at least one ABG available. Within the 10,969, the proportion of casualties experiencing hyperoxia in this population was 20.6% (2,269) with a subset of 4.1% (452) meeting criteria for extreme hyperoxia. Among those with hyperoxia, the median age was 25 years (IQR 21-30), most were male (96.8%), most frequently US forces (41.4%), injured in Afghanistan (68.3%), injured by explosive (61.1%), with moderate injury scores (median 17, IQR 10-26), and most (93.8%) survived to hospital discharge. A total of 17.8% (1,954) of the casualties underwent endotracheal intubation: 27.5% (538 of 1,954) prior to emergency department (ED) arrival and 72.5% (1,416 of 1,954) within the ED. Among those intubated in the prehospital setting, upon ED arrival 35.1% (189) were hyperoxic, and a subset of 5.6% (30) that were extremely hyperoxic. Among those intubated in the ED, 35.4% (502) were hyperoxic, 7.9% (112) were extremely hyperoxic. Within the 1,277 with a probable TBI, 44.2% (565) experienced hyperoxia and 9.5% (122) met criteria for extreme hyperoxia.

CONCLUSIONS: In our dataset, more than 1 in 5 casualties overall had documented hyperoxia on ABG measurement, 1 in 3 intubated casualties, and almost 1 in 2 TBI casualties. With limited oxygen supplies in theater and logistical challenges with oxygen resupply, efforts to avoid unnecessary oxygen supplementation may have material impact on preserving this scarce resource and avoid potential detrimental clinical effects from supraphysiologic oxygen concentrations.

J Trauma Acute Care Surg. 2019 Jul;87(1S Suppl 1):S128-S131

# ThoraSite: A device to improve accuracy of lateral decompression needle and chest tube placement.

Shah A, Kothera C, Dheer S

BACKGROUND: Multiple reports have detailed an unacceptably high error rate in the siting of decompression needles and tubes and describe associated iatrogenic injuries. The objective of the current study was to measure the accuracy of the novel ThoraSite template for identifying an acceptable intercostal space (ICS) for lateral needle or tube thoracostomy.

METHODS: Two trained operators used the ThoraSite to place radiopaque needles in the left and right lateral chests of 12 cadavers. An independent radiologist reviewed fluoroscopy images to determine the primary outcome: the ICS in which each needle was placed. Secondary outcomes were ICS's palpable through ThoraSite's Safe Zone; needle placement relative to the anterior axillary line (AAL) and midaxillary line (MAL); and percent correct placement (defined as the third, fourth, or fifth ICS from 1 cm anterior to the AAL to 1 cm posterior to the MAL).

RESULTS: The six female and six male cadavers spanned 4 ft and 11 inches (150 cm) to 6 ft and 7 inches (201 cm), 80 lb (36 kg) to 350 lb (159 kg), and 16 kg/m to 42 kg/m body mass index. All 24 needles were placed in either the third (4 [17%] of 24 needles), fourth (10 [42%] of 24 needles), or fifth ICS (10 [42%] of 24 needles). In 10 (42%) of 24 assessments, two ICSs were palpable in ThoraSite's Safe Zone. All palpable ICSs were either the third (8 [24%] of 34), fourth (15 [44%] of 34); or fifth ICS (11 [32%] of 34). Twenty-three (96%) of 24 needles were inserted from 1 cm anterior to the AAL to 1 cm posterior to the MAL. Twenty-three (96%) of 24 needle placements were correct.

CONCLUSION: ThoraSite use was associated with needle placement in the third, fourth, or fifth ICS in an area roughly spanning the AAL to MAL in anatomically diverse cadavers. By facilitating appropriate needle/tube placement, ThoraSite use may decrease iatrogenic injuries. Future study involving representative users may be useful to further evaluate ThoraSite accuracy.

Mil Med. 2019 Jun 28; Epub ahead of print

# An Evaluation of a Novel Medical Device Versus Standard Interventions in the Treatment of Tension Pneumothorax in a Swine Model (Sus scrofa).

Sheldon R, Do W, Forte D, Weiss J, Derickson M, Eckert M, Martin M

INTRODUCTION: Tension pneumothorax is a common cause of preventable death in trauma. Needle decompression is the traditional first-line intervention but has high failure rates. We sought to evaluate the effectiveness and expedience of needle thoracostomy, surgical tube thoracostomy, and Reactor™ thoracostomy – a novel spring-loaded trocar insertion device.

MATERIALS AND METHODS: Yorkshire swine underwent controlled thoracic insufflation to create tension pneumothorax physiology for device comparison. Additional experiments were performed by increasing insufflation pressures to achieve pulseless electrical activity. Intervention was randomized to needle thoracostomy (14 gauge), tube thoracostomy (32Fr), or Reactor™ thoracostomy (36Fr). Air leak was simulated throughout intervention with 40-80 mL/kg/min insufflation. Intrathoracic pressure monitoring and hemodynamic parameters were obtained at 1 and 5 minutes.

RESULTS: Tension physiology and tension-induced pulseless electrical activity were created in all iterations. Needle thoracostomy (n = 28) was faster at 7.04 ± 3.04 seconds than both Reactor thoracostomy (n = 32), 11.63 ± 5.30 (p < 0.05) and tube thoracostomy (n = 32), 27.06 ± 10.73 (p < 0.01); however, Reactor™ thoracostomy was faster than tube thoracostomy (p < 0.001). Physiological decompression was achieved in all patients treated with Reactor™ and tube thoracostomy, but only 14% of needle thoracostomy. Cardiac recovery to complete physiologic baseline occurred in only 21% (6/28) of those treated with needle thoracostomy whereas Reactor™ or tube thoracostomy demonstrated 88% (28/32) and 94% (30/32) response rates. When combined, needle thoracostomy successfully treated tension pneumothorax in only 4% (1/28) of subjects as compared to 88% (28/32) with Reactor™ thoracostomy and 94% (30/32) with tube thoracostomy (p < 0.01).

CONCLUSIONS: Needle thoracostomy provides a rapid intervention for tension pneumothorax, but is associated with unacceptably high failure rates. Reactor™ thoracostomy was effective, expedient, and may provide a useful and technically simpler first-line treatment for tension pneumothorax or tension-induced pulseless electrical activity.

Am J Surg. 2019 Dec;218(6):1138-1142

# Prehospital needle thoracostomy: What are the indications and is a post-trauma center arrival chest tube required?

Axtman B, Stewart K, Robbins J, Garwe T, Sarwar Z, Gonzalez R, Zander T, Balla F, Albrecht R

OBJECTIVE: This study examined the indications for prehospital needle thoracostomy (pNT), the need for tube thoracostomy (TT) following pNT, and the outcomes of patients who underwent pNT.

METHODS: This study is a retrospective chart review of patients who underwent pNT prior to trauma center arrival. Patients were identified from the trauma registry and a quality improvement (QI) database from 9/2014-9/2018.

RESULTS: 59 patients underwent 63 pNTs during the time period. The indication for pNT was "hypotension" in only 5 patients (7.9%). A CT chest was obtained on 51 NT attempts with the catheter in place. In 48 (94.1%) NT attempts, the catheter was not in the pleural space. 44 (69.4%) TTs were placed on admission date.

CONCLUSION: In patients undergoing pNT, hypotension was rarely the indication. Additionally, CT identified the catheter within the pleural space in only 3 (5.8%) NT attempts. TT placement was performed in 79.3% of NT attempts.

#### CHEST TUBE

Ann Thorac Surg. 2019 Dec;108(6):e405-e407

# Surgical Management of Iatrogenic Left Ventricle Perforation by Chest Tube Insertion.

Varghese S, Slottosch I, Saha S, Wacker M, Awad G, Wippermann J, Scherner M

Chest tube thoracostomy is a standard procedure in every intensive care unit. Although it is regarded as a safe procedure in experienced hands, rare complications do occur. This report describes iatrogenic perforation of the left ventricle after placement of an intercostal catheter and the successful surgical management of this injury. Various operative situations that may arise in relation to iatrogenic perforation of the left ventricle are also discussed, as well as steps to manage this potentially life-threatening complication.

Am J Crit Care. 2019 Nov;28(6):415-423

# Comparative Evaluation of Chest Tube Insertion Site Dressings: A Randomized Controlled Trial.

Wood M, Powers J, Rechter J

BACKGROUND: Little empirical evidence is available to guide decisions on what type of dressing to use and how often to change the dressing after placement of a thoracostomy tube.

OBJECTIVES: This prospective randomized controlled study was conducted to compare various dressing types and procedures after placement of thoracic and mediastinal chest tubes. Outcome measures included length of time between dressing changes, skin integrity, air leak presence, and patient-reported pain.

METHODS: The study involved a convenience sample of 127 patients with 236 chest tubes from 3 intensive care units at a midwestern regional medical center. The patients were randomized to 1 of 3 groups: (1) gauze and tape dressing changed once daily, (2) gauze and tape dressing changed every 3 days, and (3) silicone foam dressing changed every 3 days.

RESULTS: Patients with silicone foam dressings reported less pain at the insertion site than did patients with standard gauze and tape dressings, and patients with daily dressing changes reported significantly more pain with dressing removal than did patients with dressing changes every 3 days. The silicone foam dressing was associated with better skin integrity than the gauze and tape dressing. Dressing intactness, number of days with a chest tube inserted, and patient demographic characteristics did not differ significantly among the 3 groups.

CONCLUSIONS: Overall, the best type of dressing for promoting skin integrity and patient comfort was the silicone foam dressing. The results of this study may help identify best practices for dressing type and procedures among patients with chest tubes.