Chest tube insertion direction: is it

always necessary to insert a chest

tube posteriorly in primary trauma
care?
Shokei Matsumoto,MD , Kazuhiko Sekine,MD , Tomohiro Funabiki,MD ,
Motoyasu Yamazaki,MD , Tomohiko Orita,MD , Masayuki Shimizu,MD ,
Kei Hayashida,MD , Masanobu Kishikawa,MD , Mitsuhide Kitano,MD.

Rafki Hidayat
Background
The advanced trauma life support guidelines suggest that, in primary
care, the chest tube should be placed posteriorly along the inside of
the chest wall. A chest tube located in the posterior pleural cavity is of
use in monitoring the volume of hemothoraces. However, posterior
chest tubes have a tendency to act as nonfunctional drains for the
evacuation of pneumothoraces, and additional chest tube may be
required. Thus, it is not always necessary to insert chest tubes
posteriorly. The purpose of this study was to determine whether
posterior chest tubes are unnecessary in trauma care.
Methods
2.1. Patients and clinical management
This non interventional, observational study was conducted in the
Emergency and Trauma Centre, a tertiary-care hospital in Japan from
January 1, 2008, to December 31, 2013. Consecutive adult blunt
trauma patients, who were diagnosed with traumatic
pneumothoraces at a primary trauma survey using a chest x-ray ,were
prospectively enrolled.
Patients who had cardiopulmonary arrest, hemothoraces without
pneumothorax, and/or occult pneumothorax were excluded.
1. The chest tube was
managed with a water
seal drainage system
without suction
2.The direction of tube
insertion (posterior or
anterior) was
determined on a case-
by-case basis after a
review of the images
and the clinical findings
in primary trauma care.
3. After chest tube
insertion and
resuscitation, CT scans
were performed with 64
multidetector CT
scanners.
 2.2. Data collection and definitions
a.demographics
b.injury severity score (ISS)
c.the presence of rib fractures
d.shock
e.pulmonary opacities on chest x-ray
f. volume of hemothorax via chest tube
g.the need for intubation
h.hemostatic procedure
i. outcomes.
Results
During this study, a total of 4542 patients entered the emergency
department (ED) as trauma victims, and 190 patients were diagnosed
with traumatic pneumothorax.
From this subset, 115 patients were excluded (17 patients who had
cardiopulmonary arrest and 98 who had occult pneumothorax). The
remaining 75 patients, with 3 of these patients having bilateral
pneumothoraces, met our study criteria.
All these enrolled patients received chest tubes in the ED. The 7 residents
(4 in emergency medicine and 3 in general surgery) who performed the
chest tube insertions had trained for an average of 3 years.
3.1. Predictors of massive acute hemothorax in
the ED
3.2. Malposition of chest tube from different
directions (posterior or anterior)
Conclusion

Chest tubes did not need to be directed posteriorly in many trauma cases.

Posterior chest tubes have a high incidence of being mal positioned.

This mal positioning may be prevented by judging the necessity for posterior
insertion.