Sinai Grace Hospital, Department of Surgery, Detroit, MI.
University of Texas Southwestern Medical Center, Division of Burn, Trauma, Acute, and Critical Care Surgery, Dallas, TX. Electronic address: https://twitter.com/nagaraj_madhuri.
Surgery. 2023 Apr;173(4):1086-1092. doi: 10.1016/j.surg.2022.12.028. Epub 2023 Feb 3.
Emergency department tube thoracostomy is a common procedure; however, assessing procedural skills is difficult. We sought to describe procedural variability and technical complications of emergency department tube thoracostomy using trauma video review. We hypothesized that factors such as hemodynamic abnormality lead to increased technical difficulty and malpositioning.
Using trauma video review, we reviewed all emergency department tube thoracostomy from 2020 to 2022. Patients were stratified into hemodynamically abnormal (systolic blood pressure <90 or heart rate >120) and hemodynamically normal (systolic blood pressure ≥90 or heart rate ≤120). Emergency department tube thoracostomies outside of video-capable rooms, with incomplete visualization, or in patients undergoing cardiopulmonary resuscitation or resuscitative thoracotomy were excluded. The primary outcome was a procedure score modified from the validated tool ranging from 0 to 11 (higher score indicating better performance). Also measured were procedural times to (1) decision to place, (2) pleural entry, and (3) procedure completion. Postprocedure x-ray and chart review were used to determine accuracy.
In total, 51 videos met the inclusion criteria. The median age was 34 [interquartile range 24-40] years, body mass index 25.8 [interquartile range 21.8-30.7], predominately male (75%), blunt injury (57%), with Injury Severity Score of 22 [14.5-41]. The median procedure score was 9 [7-10]. Emergency department tube thoracostomies in patients with abnormal hemodynamics had significantly lower procedure scores (8 vs 10, P < .05). Hemodynamically abnormal patients had significantly shorter times from decision to proceed to pleural entry (4.05 vs 8.25 minutes, P < .001), and to completion (6.31 vs 14.23 minutes, P < .001). The most common complication was malpositioning (35.1%), with no significant difference noted when comparing hemodynamically normal and abnormal patients (P = .41).
Using trauma video review we identified significant procedural variability in emergency department tube thoracostomy, mainly that hemodynamic abnormality led to lower proficiency scores and increased malpositioning. Efforts are needed to define procedural benchmarks and evaluation in the context of patient outcomes. Using this technology and methodology can help establish procedural norms.
急诊科胸腔引流管是一种常见的操作，但评估操作技能是很困难的。我们试图使用创伤视频回顾来描述急诊科胸腔引流管的操作变异性和技术并发症。我们假设，如血流动力学异常等因素会导致操作难度增加和定位不当。
使用创伤视频回顾，我们回顾了 2020 年至 2022 年所有的急诊科胸腔引流管。将患者分为血流动力学异常（收缩压<90mmHg 或心率>120 次/分）和血流动力学正常（收缩压≥90mmHg 或心率≤120 次/分）。排除了不在视频可用室、可视化不完整、正在进行心肺复苏或抢救性开胸的患者。主要结局是从经过验证的工具中修改的程序评分，范围为 0 至 11 分（分数越高表示表现越好）。还测量了从（1）决定放置、（2）进入胸腔和（3）完成操作的操作时间。术后 X 光和图表回顾用于确定准确性。
共有 51 个视频符合纳入标准。患者的中位年龄为 34 岁[四分位距 24-40]，体重指数为 25.8[四分位距 21.8-30.7]，主要为男性（75%），钝性损伤（57%），损伤严重程度评分 22[14.5-41]。中位数程序评分为 9[7-10]。血流动力学异常患者的操作评分明显较低（8 分与 10 分，P<.05）。血流动力学异常患者从决定进入胸腔到完成操作的时间明显缩短（4.05 分钟与 8.25 分钟，P<.001）。最常见的并发症是定位不当（35.1%），血流动力学正常和异常患者之间无显著差异（P=.41）。
使用创伤视频回顾，我们发现急诊科胸腔引流管操作存在显著的操作变异性，主要是血流动力学异常导致操作熟练度评分降低和定位不当增加。需要努力定义患者结局背景下的操作基准和评估。使用这项技术和方法可以帮助建立操作规范。
