Braden McIntosh EBM: Chest Tubes Outline Cases Background Anatomy Pathophys How work Indications
ACEP guidelines PICO Papers Conclusions Case 1 60 obese M, high speed MVC, no SB, complaining of chest pain and sob.Exam shows decreased breath sounds on right and trachea deviated to the left. Case 2 18 y/o F stabbed by angry bf in the right chest complaining of shortness of breath. US shows the following: Background Chest tubes are the #1 intrathoracic intervention in chest trauma Procedure everybody needs to know how to do Anatomy Pathophys Chest tube function Indications Blunt trauma and penetrating trauma resulting in PTX or hemothorax Pleural effusion Malignant Effusions Empyema drainage Spontaneous PTX Placement We all learned 5th intercostal space ant axillary line
Triangle of Safety Direction Posterior placement Direction Failure Failure continued DOES IT MATTER? PICO Population Intervention Comparison Outcome
Population- M&F 18-65, trauma Intervention- tube thoracostomy Comparison- placement Outcome- residual effusion/ drainage/ mortality/ hospital los/ need for further intervention Critical Appraisal Design? Methods appropriate? Bias?
Statistical Analysis correct? Do data justify conclusions Objective, independent and balanced? Relevance? Add anything new? Paper 1 J. Trauma and Acute Care Surgery, Feb 2015 Question: see title
Study type:retrospective 291 patients (8186 screened, 862 tube, 571 died or ed thoracotomy or not ct) Inclusion criteria: all pts receiving chest tube 2/2 trauma as part of initial managementwho had a CT showing position of the chest tube Definitions: based on end of tip could be anterior, lateral, or posterior placement (60degrees), and high or low (6th rib), tubes placed in fissure recorded as such Removal determined clinically or by absence of airleak, radiographic resolution, drainage 190 traumatic ptx > (115 excluded for arrest or occult ptx) > 75 pts Inclusion criteria: traumatic pneumothorax on cxr Methods:Placed ant axillary line and directed anteriorly or placed mid axillary and directed posteriorly based on clinical findings Definitions/ outcomes: functional malposition defined by residual ptx requiring repositioning or another tube inserted Stats:used Chi^2 for univariate and paired t testing w/ p