ERcast: Clinical Perspectives Podcast Preview
The summary below is from an episode of ERcast: Clinical Perspectives
Not every traumatic pneumothorax on positive-pressure ventilation needs a chest tube. Recent trauma literature also supports 14 Fr drainage for hemothorax and targeted antibiotic prophylaxis for tube thoracostomy, especially after penetrating injury.
Chest Tube Decisions in Trauma
- Occult pneumothorax observation: Occult pneumothorax in a stable, mechanically ventilated trauma patient can often be watched rather than drained, especially when extubation is expected within 4 days.
- Low tension progression rate: Progression to tension physiology was uncommon in the pooled data, and most observed patients never needed any intervention. We get into the selection nuances in the episode.
- Rescue tube strategy: Patients initially observed and later needing tube thoracostomy had fewer overall complications than those getting an upfront prophylactic chest tube.
- Small-bore hemothorax drainage: Traumatic hemothorax can be managed with a 14 Fr percutaneous catheter, with failure rates comparable to traditional 28-32 Fr chest tubes.
- Pain and satisfaction advantage: Smaller percutaneous tubes were associated with less pain and better patient-reported satisfaction, a meaningful bedside advantage when drainage efficacy is equivalent.
Antibiotics for Tube Thoracostomy
- Penetrating trauma benefit: Prophylactic antibiotics reduce empyema after chest tube placement, with the clearest benefit seen in penetrating trauma.
- Skin flora coverage: The microbiology signal is skin flora, making a first-generation cephalosporin a practical first-line choice for prophylaxis.
- Procedure-timed dosing: Best-supported prophylaxis starts at the time of tube insertion and continues briefly afterward rather than becoming a prolonged antibiotic course.
- Focused outcome effect: The observed benefit is lower empyema rates, without a clear pooled reduction in pneumonia or mortality. We walk through what that means in the chapter.
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References:
- Smith JA, et al. Conservative management of occult pneumothorax in mechanically ventilated patients: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2021;91(6):1025-1040. PMID: 34225346
- Kulvatunyou N, Bauman ZM, Zein Edine SB, et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma Acute Care Surg. 2021;91(5):809-813. PMID: 33843831
- Freeman JJ, et al. Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open. 2022;7(1):e000886. Published 2022 Oct 25. PMID: 36312819
Faculty
- Chris Hicks, MD
Chris Chris Hicks is an emergency physician, trauma team leader, educator, and speaker with expertise in resuscitation, simulation, and psychological performance in healthcare. His work has focused on areas such as mental practice, stress inoculation training, and improving team performance in high-stakes clinical environments. He has contributed to the development of interprofessional and simulation-based medical education initiatives and has collaborated with healthcare organizations on the design of systems, spaces, and teams to support high-performance care delivery. Chris is also a longtime supporter of the FOAMed movement and is widely recognized for his engaging and practical approach to medical education. Outside of medicine, he enjoys running, cycling, boxing, music, and spending time with his family.
- Drew Kalnow, DO
Dr. Drew Kalnow is an emergency medicine physician and educator based in Columbus, Ohio. He completed his emergency medicine training at OhioHealth Doctors Hospital Emergency Medicine Residency. Dr. Kalnow is passionate about advancing emergency medicine through high-quality education, with a particular focus on simulation, learning theory, and innovative teaching.
