Chest Tube Placement in Mechanically Ventilated Trauma Patients: Differences between Computed Tomography-Based Indication and Clinical Decision

Abstract

The rate of occult pneumothorax in intubated and mechanically ventilated trauma patients until initial computed tomography (CT) remains undetermined. The primary aims of this study were to analyze initial chest CTs with respect to the thoracic pathology of trauma, the clinical injury severity, and chest tube placement (CTP) before and after CT. In a single-center retrospective analysis of 616 intubated and mechanically ventilated adult patients admitted directly from the scene to the emergency department (ED), 224 underwent CTP (36%). Of these, 142 patients (62%) underwent CTP before CT, of which, 125 (88%) had significant chest injury on CT. Seventeen patients had minor or absent chest injuries, most of which were associated with transient or unrecognized tracheal tube malposition. After CT, CTP was performed in another 82 patients, of which, 56 (68.3%) had relevant pneumothorax and 26 had minor findings on CT. Sixty patients who had already undergone CTP before CT received another CTP after CT, of which, 15 (25%) had relevant pneumothorax and 45 (75%) had functionality issues or malposition requiring replacement. Nine patients showed small pneumothorax on CT, and did not undergo CTP (including four patients with CTP before CT). The physiological variables were unspecific, and the trauma scores were dependent on the CT findings for identifying patients at risk for CTP. In conclusion, the clinical decisions for CTP before CT are associated with relevant false-negative and false-positive cases. Clinical assessment and CT imaging, together, are important indicators for CTP decisions that cannot be achieved by using clinical assessment or CT alone.

Are Chest Radiographs or Ultrasound More Accurate in Predicting a Pneumothorax or Need for a Thoracostomy Tube in Trauma Patients?

“…The early detection of pneumothoraces is potentially critical in treating patients with traumatic injuries because failure to treat them can be life-threatening. 1,2 Advanced Trauma Life Support (ATLS) recommends employing a chest radiograph (CXR) or Extended Focused Assessment with Sonography in Trauma (eFAST) chest ultrasound (CUS) to rapidly detect clinically significant pneumothoraces during the initial trauma assessment, and most trauma centers employ 1 or both in this pursuit. 3 Thoracic computed tomography (CT) is the gold standard for diagnosing pneumothorax (PTX); however, it is costly, time-consuming, and exposes the patient to increased radiation.…”

The outcome in critically ill patients admitted for thoracic trauma – A single center analysis over one year

“…Moreover, admission to the intensive care unit (ICU) is necessary for over 80% of patients diagnosed with flail chest, while close to 60% of these patients will need mechanical ventilation (MV), and around 20% of these patients will have tracheostomy [7,10]. Nevertheless, accurately diagnosing traumatic injuries by clinical methods might provide challenges, particularly in life-threatening rescue scenarios [11]. The use of prompt total-body computed tomography (CT) scanning in emergency protocols has emerged as a significant advancement in trauma treatment during recent decades.…”

“…The use of prompt total-body computed tomography (CT) scanning in emergency protocols has emerged as a significant advancement in trauma treatment during recent decades. This development has played a crucial role in facilitating the identification of potentially fatal injuries in a consistent manner [11,12]. Blunt and open thoracic trauma encompasses a range of injuries that can be classified into various categories based on their impact on anatomical structures.…”