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Clamp the the chest tube?

John Filangeri JohnFilangeri at att.net
Sat Apr 8 15:33:45 BST 2006


What a wonderful concept. Now, if we could only apply it to medical practice 
accross the board in this country. We could probably eliminate at least 50 
percent of what is done, and 90 percent of what is profitable. That should 
solve the healthcare financing crisis. It might even save GM. Of course, it 
would put a huge dent in Mercedes and BMW sales.

Just a thought.


John



----- Original Message ----- 
From: <docrickfry at aol.com>
To: <trauma-list at trauma.org>
Sent: Saturday, April 08, 2006 8:41 AM
Subject: Re: Clamp the the chest tube?


> Ahhhh...this argument always manages to rear its ugly head at some point--
> "Well, you know, evidence is fine, data-based medicine is fine, until, 
> that is, that is fails to support something that I just want to 
> do--then....MY own imagination and what I think sounds logical  prevails"
> Remember just 250 years ago this same argument was used for 
> bloodletting--perfectly logical to everybody, lets out the evil humors, 
> plenty of anecdotal cases of how people suddenly felt better, etc--who 
> needs data for such OBVIOUSLY beneficial intervention?  Then the data came 
> out, and guess what--not only no benefit, but it KILLED!  Same with 
> electro-shock Rx, frontal lobotomy--without a QA process applied, any 
> interventio is DANGEROUS until PROVEN otherwisw--why?  Because THAT, not 
> the opposite, is what is SAFEST for the patient.
> And we think witch doctors were only a thing of the past.....
> ERF
>
> -----Original Message-----
> From: Mike MacKinnon <mmackinnon at cox.net>
> To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
> Sent: Fri, 7 Apr 2006 20:25:42 -0700
> Subject: Re: Clamp the the chest tube?
>
>
> Hey Dr. KM
>
>
>
> No data to my knowledge. However, just because something hasn't been 
> studied
> doesn't mean it has no empirical benefit (i.e.: the classic parachute
> example).
>
>
>
> The procedure is utilized in air med for the same reasons (more stringent 
> I
> would suggest) as in the trauma room. Patient in extremis with clear chest
> tube indication and long transport times. I can tell you, no more than 1-2
> of these are done a year at my service and everything done is reviewed by
> our 4 med directors and the receiving trauma surgeon. While there is no 
> data
> I would suggest that with those two groups in agreement that the patient
> needed a chest tube and it was justified that there is oversight and 
> control
> in regards to such a high risk procedure.
>
>
>
> Really, are you suggesting you need a peer reviewed study to show 
> indication
> for a procedure that is a "no brainer" and clinically driven in the trauma
> room? The indications for air med are few and far between for chest tubes
> (much less than in the trauma room).
>
>
>
> In anycase, here are three studies which I found after a quick search.
>
>
>
> Prehosp Emerg Care. 2005 Apr-Jun;9(2):191-7.
>
>
>
>
>
> The safety and efficacy of prehospital needle and tube thoracostomy by
> aeromedical personnel.
>
>
>
> Davis DP, Pettit K, Rom CD, Poste JC, Sise MJ, Hoyt DB, Vilke GM.
>
>
>
> Department of Emergency Medicine, UCSD, San Diego, CA 92103, USA.
> davismd at cox.net
>
>
>
> BACKGROUND: Aeromedical crews routinely use needle thoracostomy (NT) and
> tube thoracostomy (TT) to treat major trauma victims (MTVs) with potential
> tension pneumothorax; however, the efficacy of prehospital NT and TT is
> unclear. OBJECTIVES: To explore the efficacy of aeromedical NT and TT in
> MTVs. METHODS: A retrospective chart review was performed using 
> prehospital
> medical records and the county trauma registry over a seven-year period. 
> All
> MTVs undergoing placement of NT or TT by aeromedical personnel were 
> included
> patients with incomplete data were excluded. Descriptive statistics were
> used to report the incidence of air release, clinical improvement 
> (improved
> breath sounds or compliance if intubated, decreased dyspnea if 
> nonintubated)
> and vital signs improvements (systolic blood pressure [SBP] increase to 
> =90
> mm Hg or increase by 5 mm Hg if < 90 mm Hg; heart rate improvement to 
> 60-100
> beats/min, increase by 10 beats/min if < 60 BPM, or decrease by 10 
> beats/min
> if > 100 beats/min; oxygen saturation increase if < 95%) for both NT and 
> TT
> as documented in prehospital medical records. Survival and improvement in
> SBP based on trauma registry data were recorded for patients stratified by
> initial SBP. RESULTS: A total of 136 procedures (89 NTs and 47 TTs) in 81
> patients were identified using prehospital medical records over a 
> four-year
> period. Response rates to NT (60% overall, 32% vital signs) and TT (75%
> overall, 60% vital signs) were high. Vital signs improvements were 
> observed
> more often in patients with a pulse and in nonintubated patients. A total 
> of
> 168 patients were identified in the trauma registry over the seven-year
> study period. Normalization of SBP was observed in two-thirds of patients
> with a field SBP = 90 mm Hg and one-third of patients in whom field SBP
> could not be obtained. A small but significant proportion of patients
> undergoing prehospital NT and TT, including some with prehospital
> hypotension and high injury severity, survived to hospital discharge. The
> incidence of complications was low. CONCLUSIONS: Aeromedical crews appear 
> to
> appropriately select MTVs to undergo field NT or TT. A low incidence of
> complications and a small but significant group of unexpected survivors
> support continued use of this procedure by aeromedical personnel.
>
>
>
> J Emerg Med. 1995 Mar-Apr;13(2):155-63.
>
>
>
>
>
> Prehospital needle aspiration and tube thoracostomy in trauma victims: a
> six-year experience with aeromedical crews.
>
>
>
> Barton ED, Epperson M, Hoyt DB, Fortlage D, Rosen P.
>
>
>
> Department of Emergency Medicine, University of California, San Diego
> Medical Center 92013-8676, USA.
>
>
>
> The use of prehospital tube thoracostomy (TT) for the treatment of 
> suspected
> tension pneumothorax (TPtx) in trauma patients is controversial. A study 
> is
> presented that reviews a 6-year experience with the use of needle catheter
> aspiration (NA) and chest tubes performed in the field by air medical
> personnel. Prehospital flight charts and hospital records from 207 trauma
> patients who underwent one or both of these procedures in the field were
> retrospectively reviewed. The clinical indications used to determine
> treatment are presented for both procedures. Improvement in clinical 
> status
> of patients observed by flight personnel were similar for both treatment
> groups (54% for NA, 61% for TT). Thirty-two (38%) of the TT patients had
> failed NA attempts prior to chest tube placement. Average time on scene 
> (T.O
> S.) was significantly greater for the TT group (25.7 min versus 20.3 min 
> for
> NA group). Fewer patients were pronounced dead on arrival (D.O.A.) with TT
> treatment compared to NA alone (7% versus 19%, respectively). Injury
> severity scores, number of hospital complications, length of stay 
> (L.O.S.),
> and total hospital costs were not different between the two groups. There
> were no cases of lung damage or empyema formation associated with
> prehospital TT treatment. Overall mortality was similar for both groups.
>>From these data, we conclude that NA is a relatively rapid intervention in
> the treatment of suspected TPtx in the prehospital setting; however, TT is
> an effective adjunct for definitive care without increasing morbidity or
> mortality. A better understanding of the physiology of intrapleural air
> masses is needed to determine the most effective decompression 
> requirements
> prior to aeromedical transport.
>
>
>
> J Trauma. 2005 Jul;59(1):96-101.
>
>
>
> Prehospital chest tube thoracostomy: effective treatment or additional
> trauma?
>
>
>
> Spanjersberg WR, Ringburg AN, Bergs EA, Krijen P, Schipper IB.
>
>
>
> Department of General Surgery and Traumatology, University of Rotterdam,
> Erasmus Medical Center, The Netherlands.
>
>
>
> BACKGROUND: The use of prehospital chest tube thoracostomy (TT) remains
> controversial because of presumed increased complication risks. This study
> analyzed infectious complication rates for physician-performed prehospital
> and emergency department (ED) TT. METHODS: Over a 40-month period, all
> consecutive trauma patients with TT performed by the flight physician at 
> the
> accident scene were compared with all patients with TT performed in the
> emergency department. Bacterial cultures, blood samples, and thoracic
> radiographs were reviewed for TT-related infections. RESULTS: Twenty-two
> patients received prehospital TTs and 101 patients received ED TTs. 
> Infected
> hemithoraces related to TTs were found in 9% of those performed in the
> prehospital setting and 12% of ED-performed TTs (not significant).
> CONCLUSION: The prehospital chest tube thoracostomy is a safe and 
> lifesaving
> intervention, providing added value to prehospital trauma care when
> performed by a qualified physician. The infection rate for prehospital TT
> does not differ from ED TT.
>
>
>
> Mike M.
>
>
>
> -------Original Message-------
>
>
>
> From: KMATTOX at aol.com
>
> Date: 04/07/06 20:02:20
>
> To: trauma-list at trauma.org
>
> Subject: Re: Clamp the the chest tube?
>
>
>
>
>
> In a message dated 4/7/2006 10:00:15 P.M. Central Standard Time,
>
> mmackinnon at cox.net writes:
>
>
>
>
>
> Happens all the time Dr. Mattox. Long transport times where  patients are
>
> severly injured and need a completely justifiable chest  tube.
>
>
>
>
>
>
>
>
>
> True true and unrelated.    Show me the  data.   I know of no good data
> which
>
> has been peer reviewed by the  Trauma service in critique of flight 
> services
>
>
>  Flight services  procedures are among the most out of control of any in
>
> medicine.
>
>
>
> k
>
> --
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