Complications of Tube Thoracostomy Placement in the ED

In This Article

Abstract and Introduction

Abstract

Background: Emergency medicine residents frequently perform invasive procedures, including tube thoracostomy (TT), that inherently place patients at risk for complications. Objectives: The purpose of the study was to assess the prevalence and types of complications from TT in an academic emergency department (ED).
Methods: A combined prospective and retrospective, observational study of all patients who had TT between December 2002 and January 2006 was performed. Exclusion criteria included age < 15 years and tube placement at an outside facility. Complications detected in the ED were defined as immediate, whereas those discovered later were defined as delayed. Complications requiring corrective surgical intervention, administration of blood products, or intravenous antibiotics were defined as major. Bivariate and multivariate analyses were used to identify operator and patient factors associated with complications.
Results: TTs were placed in 242 patients, and 90 (37%; 95% confidence interval [CI] 31.1–43.3%) experienced a complication. Major complications included one intercostal artery laceration, one retroperitoneal placement, and empyema in 2 patients. In multivariate analysis, blunt injury excluding motor vehicle accidents (odds ratio [OR] 2.57; 95% CI 1.27–5.21) and spontaneous pneumothorax (OR 3.84; 95% CI 1.80–8.18) were associated with all complications. TT size < 36 French and blunt injury excluding motor vehicle accidents were associated with immediate complications and spontaneous pneumothorax was associated with delayed complications.
Conclusions: The vast majority of complications from TT in the ED were minor. The prevalence of complications was consistent with previous reports of TTs placed by non-emergency-medicine-trained physicians outside the ED. The findings can be used to identify avoidable complications and improve residency training.

Introduction

Tube thoracostomy (TT) is an example of an invasive procedure that inherently places patients at risk for complications. Potential complications include misplacement of the tube, unresolved pneumothorax, empyema, laceration of thoracic vessels, and injury to the lung and heart. Although previous studies describe complications from TT in various hospital settings performed by physicians from a variety of specialties, occurrences in an academic emergency department (ED) with an emergency medicine residency have not been described extensively.^[1–4] The purpose of this investigation was to evaluate the prevalence and types of complications resulting from TT insertion in a setting where the procedure is primarily performed by emergency medicine residents and to identify specific patient and procedural characteristics that may predict the potential for complications. Predictors of complications were identified by multivariate logistic regression analysis. This information may be used to reduce the risk of adverse outcomes to patients from TT by identifying the prevalence and types of complications and by guiding further procedural training.

Cite this: Complications of Tube Thoracostomy Placement in the Emergency Department - Medscape - Jan 01, 2011.

Table 1. Mechanism of Injury in 242 Patients Requiring TT in the ED
Mechanism	Number of Patients (% of Total)
Penetrating trauma (total)	97(40%)
Gunshot wounds	32(13.2%)
Stab wounds	65(26.9%)
Blunt trauma (total)	104(43.0%)
Motor vehicle accidents	62(25.6%)
Blunt injury	42(17.4%)
Spontaneous pneumothorax	37(15.3%)
Iatrogenic pneumothorax	2(0.8%)
S/P needle decompression per EMS	2(0.8%)

* Includes falls, motorcycle, boating, and plane accidents, and pedestrians struck by motor vehicles.

Table 2. Complications of ED TT Placement in 90 Patients
Immediate complications (total)	63(70.0%)
Intercostal vessel laceration	1(1.1%)
Retroperitoneal placement	1(1.1%)
Misplacement
Kinked	9(10.0%)
Advanced too deeply	26(28.9%)
Advanced too deeply and kinked	4(4.4%)
Inadequately advanced	11(12.2%)
Unresolved pneumothorax	11(12.2%)
Delayed complications (total)	40(44.4%)
Empyema	2(2.2%)
Reaccumulation of pneumothorax	35(38.9%)
Insertion site infection	2(2.2%)
Persistent pleural effusion	1(1.1%)

* 13 patients had both an immediate and a delayed complication.

Table 3. Multivariate Analysis: Factors Associated with Any Immediate or Delayed Complications
All Complications	Odds Ratios (95% Confidence Interval)
Blunt injury	2.57(1.27–5.21)
Spontaneous pneumothorax	3.84(1.80–8.18)
Immediate complications
Chest tube size < 36 Fr	2.94(1.54–5.55)
Blunt injury	3.03(1.45–6.33)
Delayed complications
Spontaneous pneumothorax	5.75(2.64–12.50)

* Includes falls, motorcycle, boating, and plane accidents, and pedestrians struck by motor vehicles.

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