Complications associated with pre-hospital open thoracostomies: a rapid review

Abstract

Background Open thoracostomies have become the standard of care in pre-hospital critical care in patients with chest injuries receiving positive pressure ventilation. The procedure has embedded itself as a rapid method to decompress air or fluid in the chest cavity since its original description in 1995, with a complication rate equal to or better than the out-of-hospital insertion of indwelling pleural catheters. A literature review was performed to explore potential negative implications of open thoracostomies and discuss its role in mechanically ventilated patients without clinical features of pneumothorax. Main findings A rapid review of key healthcare databases showed a significant rate of complications associated with pre-hospital open thoracostomies. Of 352 thoracostomies included in the final analysis, 10.6% (n = 38) led to complications of which most were related to operator error or infection (n = 26). Pneumothoraces were missed in 2.2% (n = 8) of all cases. Conclusion There is an appreciable complication rate associated with pre-hospital open thoracostomy. Based on a risk/benefit decision for individual patients, it may be appropriate to withhold intervention in the absence of clinical features, but consideration must be given to the environment where the patient will be monitored during care and transfer. Chest ultrasound can be an effective assessment adjunct to rule in pneumothorax, and may have a role in mitigating the rate of missed cases.

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

“…Point-of-care ultrasound (POCUS) devices in the prehospital and trauma room settings for the confirmation of pneumothorax prior to CT might contribute to avoiding unnecessary chest tube placement until CT diagnostics [ 14 , 15 , 16 , 17 ]. However, it should be noted that the interpretation of ultrasound considerably depends on the expertise of the examiner, and thus, CT is currently regarded as the standard of care [ 18 , 19 , 20 ].…”