Are Chest Tubes Passe in the Treatment of Traumatic Pnumothorax?

Many would be aware that although there has been a move to treat small and occult pneumothoraces with observation, in general a significant pneumothorax is treated by the insertion of a thoracostomy tube. However it is not altogether surprising that in an era where minimal intervention is a by-word there would be a move to treat traumatic pneumothorax in the same way.

This paper, from Peter Rhee and his group at the University of Arizona reviewed the performance of percutaneous pigtail catheters inserted via a Seldinger technique with standard chest tubes for treatment of prneumothorax over a 2 year period. Sadly, this was not a randomized controlled trial but rather a retrospective review of 2 years of experience in treating pneumothoraces at a Level 1 Trauma Centre. No information is given as to why some patients were treated with chest tubes and others with pigtail catheters but 386 patients were treated with chest tubes and 94 with pigtail catheters. Most of the pigtails (75) were inserted for simple pneumothoraces but some were inserted for haemothoraces and haemothoraces. Interestingly there were no significant differences in the demography or injury severity of the two patient groups but the pigtail group only stayed 6 days whereas the chest tube group stayed 15 and that difference was statistically significant. Complications occurred at an equal rate in the two groups.

While the science is not strong in this paper it is noteworthy that over the period of the study at the Trauma Centre the use of chest tubes dropped to about one third of the previous level. Interestingly, this paper earned an editorial comment and this noted that while the paper was observational the author of the editorial did not feel that a large randomized trial was necessary, rather just accumulation of more observational studies. It was felt ease of insertion and applicability to a wider range of healthcare environments and providers meant the technique should be increasingly used and the results reported.


What does this mean in the Australasian setting?

Undoubtedly this technique could be used successfully in a range of patients with simple pneumothorax in the context of minor trauma and the elderly may well reduce length of stay and cost. Recognising the problems that seem to accompany the insertion of chest tubes in Australia and NZ one could be attracted to this method. However it is worth noting that the complication rate wasn’t reduced with pigtail catheters in this study and the complications that did eventuate were major.

Conversely, if standard chest tube insertion became a less common technique and was practiced less often, the facility with this technique, which is already surprisingly low, might deteriorate further. For simple pneumothoraces and particularly in the elderly the pigtail catheter might be a good option. For the benefit of many patients who need positive pressure ventilation with major injuries and who have haemopneumothoraces, such as may be the case in many patients who trigger trauma calls, a standard chest tube, 28-36Fr in an adult, is probably the best option both for the patient, and to maintain the expertise of the trauma care providers.


The Role of Allied Health in Trauma

Trauma is the leading cause of lost years of life and productivity in young adults (Celso et al. 2006). Numerous studies including meta-analysis have confirmed a significant reduction in mortality when care is provided at a Level 1 Trauma Centre (MacKenzie et al. 2008 & Celso et al. 2006). Trauma centres employ a multitude of patient assessment techniques, management systems, human resources and infrastructure; each contributing to improving trauma patient care. With reducing mortality rates, the measurement of trauma centre success has shifted to non-fatal measures such as morbidity and improvement in functional outcomes (MacKenzie et al. 2008). It is estimated that for every trauma fatality, there are between three and four survivors who are permanently impaired (Halcomb et al. 2005) and so therapies that selectively improve the quality of life in survivors could be as valuable as therapies that decrease mortality. To date, there is no process measure that correlates with reducing disability.

Many studies of medical procedures have revealed that improved results occur in centres that perform large numbers of procedures versus centres that perform smaller numbers. The same concept is true for trauma (Markovchick & Moore 2007). Physicians, nurses and ancillary staff who care for trauma patients on a regular basis acquire and maintain valuable skills. Optimal human resources for a Level 1 Trauma Centre have been described as physicians, surgeons and other paramedical specialists all involved in the care of trauma patients on a continual basis (American College of Surgeons Committee on Trauma 2006). Specific literature and support for Allied Health in Trauma management is improving. In 2007, Pendleton, Cannada & Guerrero-Bejarano identified that Physiotherapy availability within 24 hours of surgery was an important factor in decreasing length of stay in isolated femur fractures after trauma. Furthermore, Dutton et al (2003) demonstrated that daily multi-disciplinary “discharge rounds” including Allied Health team members (physiotherapy, occupational therapy and speech therapy) provided a forum for clear communication and streamlined care, allowed a 36% increase in patient volume and 15% decrease in length of stay. More recently, advances in knowledge around the effects of immobility, intensive care unit acquired weakness and early / acute rehabilitation have helped to shape the role of specialised trauma allied health clinicians who contribute to the recovery and rehabilitation of trauma patients.

From acute inpatient phases through to community reintegration; allied health clinicians work to improve physical, cognitive and quality of life status post injury. Outcome after trauma should be considered as the sum of all residual deficits and not just organ specific. Contributions of social, economic and personal factors have to be considered as well as functional and psychological outcomes. Allied Health is a broad, encompassing term for a wide variety of clinical disciplines that are responsible for the recovery and rehabilitation of trauma patients from the acute care setting through to definitive discharge destinations. They possess a diverse range of skills and knowledge and due to the multi faceted sequale of trauma injuries, the dedication of specialist trauma clinicians in allied health disciplines should be an important factor for trauma centres to consider.

Trauma patient profile and care is changing. There is increasing pressure from organisations to maintain capacity by reducing length of stay, while still improving patient outcomes and ensuring consistency of care. With complex injuries, multi system morbidity and recovery needs, trauma management provides the perfect environment for dedicated allied health clinicians to demonstrate their role and utility. The ATS can assist in this vision, providing an important platform for Allied Health clinicians of all disciplines to work towards a strong voice and presence in trauma patient care and management.

American College of Surgeons Committee on Trauma 2006, Resources for optimal care of the injured patient, American College of Surgeons, Chicago.

Celso, B, Tepas, J, Langland-Orban, B, Pracht, E, Papa, L, Lottenberg, L & Flint, L 2006, ‘A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centres following the establishment of trauma systems’, Journal of Trauma, vol. 60, pp. 371 – 378.

Dutton, RP, Cooper, C, Jones, A, Leone, S, Kramer, ME & Scalea, TM 2003, ‘Daily multidisciplinary rounds shorten length of stay for trauma patients’, J Trauma, vol. 55, p. 913 – 919.

Halcomb, E, Daly, J, Elliott, D & Griffiths, R 2005, ‘Life beyond severe traumatic injury: an integrative review of the literature’, Australian Critical Care, vol. 18, pp. 17 – 24.

MacKenzie, EJ, Rivara, FP, Jurkovich, GJ, Nathens, AB, Egleston, BL, Salkever, DS, Frey, KP & Scharfstein, DO 2008, ‘The impact of trauma-center care on functional outcomes following major lower limb trauma’, Journal of Bone and Joint Surgery (America), vol. 90, pp. 101 – 109.

Markovchick, VJ & Moore, EE 2007, ‘Optimal trauma outcome: trauma system design and the trauma team’, Emergency Medicine Clinics of North America, vol. 25, pp. 643 – 654.

Pendleton, AM, Cannada, LK & Guerrero-Bejarano, M 2007, ‘Factors affecting length of stay after isolated femoral shaft fractures’, J Trauma, vol 62, p. 697 – 700.

Do We Need Checklists for Optimal Communication with Relatives of Trauma Patients?

This paper is not in print yet but was presented at the annual meeting of the American Association for the Surgery of Trauma (which is the parent body for the Journal of Trauma) in Chicago in September. Most would be familiar with the work of Atul Gawande and his various publications (e.g. Better, Complications, The Checklist Manifesto) and have heard of the Surgical Safety Checklist which is used the perioperative environment. But do we need a checklist even in relation to our communication with patients and their relatives?

At first glance this seems ridiculous but as has often been stated who hasn’t been sent to the supermarket by their partner for three or four items without a checklist and come home without at least one? In this research from Georgia, a study and a control group were used. In the study group residents gave information to relatives based on a checklist. This reminded them to include, amongst other things, an introduction, a list of injuries, who the patient was under, what operations were planned and whether the relatives had any questions. Control relatives were given information in a manner that was usual or the unit but without any checklist.

48 hours later the relatives were given a survey to determine the trauma team’s communication. There were 130 respondents in each group and the checklist group were better informed in relation to 8 of the 11 items in the survey including knowing who was looking after the patient, an understanding of the injuries, the upcoming investigations and the overall treatment plan.

This study challenges not only our communication processes but all aspects of our care of trauma patients. One needs to ask the question sometimes, if you were not there, how would you brief a competent healthcare provider but one who didn’t usually work in your unit to do what you do? The answer to that question would usually form the basis for a checklist. Given safe hours and the increasingly shift based delivery of care to inpatients in large hospitals the use of checklists has significant merit and this and other studies will probably continue to demonstrate more consistent and error free healthcare delivery until their use becomes ubiquitous. Using a checklist to improve family communication in trauma care.

Dennis BM, Sykes LN, Vogel RL et al. AAST abstracts, Chicago 2011.

Are Mental Health Issues a Precursor or a Consequence of Injury?

This prospective cohort study of 1084 injured patients from 4 major (unidentified) Australian trauma hospitals were recruited over a 23 month period from 2004-6 and followed up for 3 and 12 months respectively. The injuries ranged from minimum to critical based on Injury Severity Score. They were assessed for the prevalence of psychiatric disorders, quality of life, mental health service use and lifetime axis 1 psychiatric disorders. At 12 months after injury the authors found that 31% reported a psychiatric disorder and 22% developed a new psychiatric disorder.

The most common new psychiatric disorders were depression (9%), generalised anxiety disorder (9%), posttraumatic stress disorder (PTSD) (6%) and agoraphobia ( 6%). They also found that patients were more likely to develop PTSD and agoraphobia if they suffered mild traumatic brain injury. Participants were more likely to develop a psychiatric disorder at 12 months if they had physical, psychological, social or environmental impairment in function at 3 months.

These findings differ from previous studies which have shown rates of PTSD and depression in survivors of major traumatic injury to be 10-20% and 9-15% respectively. Although PTSD is the predominant disorder after traumatic events that involve significant violence, it appears that a broader range of disorders affect people after traumatic injury in general. Although there was a lack of a non-trauma-exposed comparison group, the risk of development of psychiatric illness in the trauma exposed group is five times greater than the point prevalence rate in the general Australian population.

Another interesting finding was that contrary to other studies, the rate of development of psychiatric illness did not decrease between 3 and 12 months post-traumatic injury. They found that more than half of the patients with either an anxiety or a depressive disorder at 12 months did not have the disorder at 3 months and only 33% with a psychiatric disorder sought mental health treatment before the 12 month assessment. A potential weakness of the study is that the patients were limited to weekday admissions but the overall follow-up rate of 86% and 75% at 3 and 12 months respectively was quite good.

The authors conclude that significant mental health needs are experienced by about one-third of survivors of traumatic injury and there is a need for significant public health initiatives to address the significant mental health burden associated with these injuries. The challenge for those of us who treat these patients is how to identify those with new psychiatric disorders associated with trauma and what interventions will facilitate optimum recovery from these psychiatric disorders.

The Psychiatric Sequelae of Traumatic Injury.
Bryant RA, O’Donnell ML, Creamer M et al. Am J of Psychiatry 2010;167: 312-320

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