Identifying the site for intercostal catheter insertion in the emergency department: Is clinical examination reliable?

Carter, Peter; Conroy, Sheree; Blakeney, Jade; Sood, Bimal

doi:10.1111/1742-6723.12276

Cited by 13 publications

(13 citation statements)

References 8 publications

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“…The problem arises however, that these anatomical landmarks are poorly recalled . Further, even when recalled, the landmarks are poorly identified, even more so perhaps under the cognitive demands of trauma resuscitation . Failure to correctly site the incision for either thoracostomy or chest drain is recognised as a contributor to morbidity, including iatrogenic injuries because of the incision being too low (endangering diaphragm, liver or spleen) or too high (endangering axillary vessels) .…”

Section: Discussionmentioning

confidence: 99%

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

Quinn

Palmer

Bernard

et al. 2019

Emerg Medicine Australasia

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Objective Thoracic trauma is a leading cause of paediatric trauma deaths. Traumatic cardiac arrest, tension pneumothorax and massive haemothorax are life‐threatening conditions requiring emergency and definitive pleural decompression. In adults, thoracostomy is increasingly preferred over needle thoracocentesis for emergency pleural decompression. The present study reports on the early experience of thoracostomy in children, to inform debate regarding the best approach for emergency pleural compression in paediatric trauma. Methods Retrospective review of Ambulance Victoria and The Royal Children's Hospital Melbourne, Trauma Registry between August 2016 and February 2019 to identify children undergoing thoracostomy for trauma, either pre‐hospital or in the ED. Results Fourteen children aged 1.2–15 years underwent 23 thoracostomy procedures over the 31 month period. The majority of patients sustained transport‐related injuries, and underwent thoracostomies for the primary indications of hypoxia and hypotension. Two children were in traumatic cardiac arrest. Ten children underwent needle thoracocentesis prior to thoracostomy, but all required thoracostomy to achieve the necessary definitive decompression. All patients were severely injured with multiple‐associated serious injuries and median Injury Severity Score 35.5 (17–75), three of whom died from their injuries. Thoracostomy in our cohort had a low complication rate. Conclusion In severely injured children, thoracostomy is an effective and reliable method to achieve emergency pleural decompression, including in the young child. The technical challenges presented by children are real, but can be addressed by training to support a low complication rate. We recommend thoracostomy over needle thoracocentesis as the first‐line intervention in children with traumatic cardiac arrest, tension pneumothorax and massive haemothorax. [Correction added on 23 September 2019 after first online publication: in the second sentence of the conclusion, the words “under review process” were mistakenly added and have been removed.]

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Section: Discussionmentioning

confidence: 99%

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

Quinn

Palmer

Bernard

et al. 2019

Emerg Medicine Australasia

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“…The ipsilateral arm is abducted and externally rotated as much as possible, with the patient's hand placed behind their head and restrained there. Textbooks and conventional teaching often refer to the Triangle of Safety for placement. Unfortunately, it is alarmingly common for the ICC to be placed too low in the chest . A thoracostomy incision should be at a level superior to the nipple line, in the axilla.…”

Section: What Is the Optimal Patient Position And Insertion Site For mentioning

confidence: 99%

“…Unfortunately, it is alarmingly common for the ICC to be placed too low in the chest. 3 A thoracostomy incision should be at a level superior to the nipple line, in the axilla. A good guide is the inferior margin of the axillary hairline -in most patients the correct placement will be one finger breadth below this.…”

mentioning

confidence: 99%

Intercostal catheter insertion

Butson

Kwa

2015

Emerg Medicine Australasia

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“…Another study had physicians placing a radiopaque marker on a patient’s chest wall over the 4th or 5th ICS prior to the patient getting a chest X-ray. This study demonstrated that physicians placed the marker correctly only 36.2% of the time [ 13 ]. In both of the aforementioned studies, the most common mistake made by the trainees was placing the marker for thoracostomy insertion too low [ 12 , 13 ].…”

Section: Introductionmentioning

confidence: 99%

Ultrasound-guided thoracostomy site identification in healthy volunteers

et al. 2018

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BackgroundTraditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance.Methods33 emergency medicine residents and medical students volunteered to participate in this study during routine thoracostomy tube education. A healthy volunteer was used as the standardized patient for this study. An experienced physician sonographer used ultrasound to locate a site at mid-axillary line between ribs 4 and 5 and marked the site with invisible ink that can only be revealed with a commercially available UV LED light. Participants were asked to identify the thoracostomy site by placing an opaque marker where they would make their incision. The distance from the correct insertion site was measured in rib spaces. The participants were then given a brief hands-on training session using ultrasound to identify the diaphragm and count rib spaces. The participants were then asked to use ultrasound to identify the proper thoracostomy site and mark it with an opaque marker. The distance from the proper insertion site was measured and recorded in rib spaces.ResultsThe participants correctly identified the pre-determined intercostal space using palpation 48% (16/33) of the time, versus the ultrasound group who identified the proper intercostal space 91% (30/33) of the time. On average, the traditional technique was placed 0.88 rib spaces away (95 CI 0.43–1.03), while the ultrasound-guided technique was placed 0.09 rib spaces away (95 CI 0.0–0.19) [P = 0.003].ConclusionsThe ability to accurately locate the correct intercostal space for thoracostomy incision was improved under ultrasound guidance. Further studies are warranted to determine if this ultrasound-guided technique will decrease complications with chest tube insertion and improve patient outcomes.

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Identifying the site for intercostal catheter insertion in the emergency department: Is clinical examination reliable?

Abstract: Emergency registrars and consultants sampled from a regional ED appeared unable to reliably identify the 4th or 5th ICS, as evidenced by marker position, in a heterogeneous patient population.

Cited by 13 publications

References 8 publications

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

Intercostal catheter insertion

Ultrasound-guided thoracostomy site identification in healthy volunteers

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