Are chest X-rays necessary after chest tube insertion in trauma emergencies?

Introduction

Johannesburg Hospital is a level I trauma center in Gauteng. We routinely do chest X-rays (CXRs) in indicated cases, if feasible, and prefer to perform a CXR after intercostal drain (ICD) insertion to maintain quality and direct further care [1].

Methods

A prospective data collection of patients who had injuries that required the insertion of an ICD over a period of 8 months from 1 August 2006 to 30 March 2007. A questionnaire was developed and it included the patients' demographics, mechanism of injury, reason for ICD insertion, findings of both the initial and post-ICD insertion CXR, change in management and any acute complications noted.

Results

One hundred and forty patients were identified for the study, 129 (92.1%) were males and 11 (7.9%) were females. The average age was 32 (range 11 to 64) years. Eighty-four (60%) patients sustained stab wounds and 20 (14.3%) had gunshot wounds. The remaining 36 (25.7%) sustained blunt injury. One hundred and four (74.3%) patients had an ICD inserted for both radiological and clinical findings, while 19 (13.6%) patients had drains inserted due to radiological findings and 14 (10%) patients on clinical grounds only. Three (2.1%) patients had drain insertion after CT scan findings.

In patients who had an initial CXR, clinical and/or radiological findings confirmed 47 (36.7%) patients with haemopneumothoraces, 49 (38.3%) patients with pneumothoraces, 26 patients (20.3%) with haemothoraces and four (3.1%) patients had significant surgical emphysema with fractures and two (1.6%) patients had no abnormalities on CXR. No acute complications to chest tube insertion were noted.

In 89 (63.6%) patients, the post-ICD CXR showed good position of the drain with improvement in pathology, in 31 (22.1%) patients an inadequate ICD position was noted, in 17 (12.1%) patients significant retained haemothoraces were shown and in three (2.1%) patients poor lung expansion was detected. The post-ICD CXR contributed to change in management in 29 (20.7%) of the cases. Twenty-two (15.7%) patients required a change in position of the tube, six (4.3%) had surgery performed, and one (0.7%) patient had their conservative treatment escalated. Four (2.9%) patients should have had their tubes adjusted.

Conclusion

Routine usage of post-ICD CXR contributes to a change in management in one out of five trauma patients.