Page 19 - JSOM Summer 2024

An Analysis of Tube Thoracostomy in Combat

Implications for Improved Prehospital Recognition and Treatment

Andrew D. Fisher, MD, MPAS *; Joseph Jude, MD ;
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Michael D. April, MD, DPhil, MSc ; Jason Lavender ; Xander S. Augustson ;
John C. Maitha, MPAS, APA, PA-C ; Steven G. Schauer, DO, MS 7
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ABSTRACT
Background: Thoracic trauma occurs frequently in combat and cause life-threatening, yet treatable conditions. Injuries to the
is associated with high mortality. Tube thoracostomy (chest chest wall and lung can cause the pleural cavity to fill with
tube) is the treatment for pneumothorax resulting from tho- air or blood, resulting in pneumothorax, hemothorax, or a
racic trauma, but little data exist to characterize combat casu- combination of both. During the conflicts in Afghanistan and
alties undergoing this intervention. We sought to describe the Iraq, mortality due to massive hemothorax and tension pneu-
incidence of these injuries and procedures to inform training mothorax was as high as 14% and 9%, respectively. Tube
3,4
and materiel development priorities. Methods: This is a sec- thoracostomy (chest tube) placement is often required for
ondary analysis of a Department of Defense Trauma Registry treatment of these injuries.
(DoDTR) data set from 2007 to 2020 describing prehospital
care within all theaters in the registry. We described all casu- Tube thoracostomy is a common hospital intervention, and
alties who received a tube thoracostomy within 24 hours of in the civilian setting, 18%–22% of chest injuries require a
admission to a military treatment facility. Variables described tube thoracostomy. As many as one-third of thoracic injuries
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included casualty demographics; abbreviated injury scale (AIS) may undergo treatment with tube thoracostomy alone. The
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score by body region, presented as binary serious (≥3) or not proportion of tube thoracostomies successfully placed in the
serious (<3); and prehospital interventions. Results: The data- hospital setting ranges from 90% to 95%. A previously pub-
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base identified 25,897 casualties, 2,178 (8.4%) of whom re- lished study found that in the combat setting the most common
ceived a tube thoracostomy within 24 hours of admission. Of procedure for thoracic trauma was tube thoracostomy (47%).
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those casualties, the body regions with the highest proportions Current Tactical Combat Casualty Care (TCCC) guidleines
of common serious injury (AIS >3) were thorax 62% (1,351), recommend either simple thoracostomy or chest tube in refrac-
extremities 29% (629), abdomen 22% (473), and head/neck tory shock. This is due to non-compressible torso hemorrhage
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22% (473). Of those casualties, 13% (276) had prehospital being a more common cause of potentially preventable death,
needle thoracostomies performed, and 19% (416) had limb and they therefore recommend resuscitation over chest inter-
tourniquets placed. Most of the patients were male (97%), ventions. Additionally, there is a risk of complications associ-
partner forces members or humanitarian casualties (70%), and ated with chest tube placement in the prehospital setting when
survived to discharge (87%). Conclusions: Combat casualties performed by those with less experience. There is a paucity of
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with chest trauma often have multiple injuries complicating data on tube thoracostomy in the prehospital combat setting,
prehospital and hospital care. Explosions and gunshot wounds with one study showing a total of 326 tube thoracostomies
are common mechanisms of injury associated with the need over a 13-year period. An additional study comparing med-
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for tube thoracostomy, and these interventions are often per- ical officer with enlisted medical personnel prehospital care,
formed by enlisted medical personnel. Future efforts should be demonstrated medical officers performed five-times as many
made to provide a correlation between chest interventions and tube thoracostomies (27 vs. 5). 8
pneumothorax management in prehospital thoracic trauma.
The wounds and treatments provided in the prehospital set-
Keywords: prehospital care; combat; chest wound; tube ting may offer insight for casualties that require prehospi-
thoracostomy; needle thoracostomy tal tube thoracostomy in future conflicts as well as identify
gaps in the knowledge base for future research. We sought to
evaluate and describe those casualties who received a tube
thoracostomy within 24 hours of admission and their associ-
Introduction
ated prehospital injuries and treatments in order to provide
Thoracic trauma is common in combat casualties. These insight for combat casualty care in future large-scale combat
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injuries, due to both blunt and penetrating mechanisms, may operations.
*Correspondence to Andrew D. Fisher, UNM School of Medicine, Department of Surgery, MSC10 5610, 1 University of New Mexico, Albuquer-
que, NM or anfisher@salud.unm.edu
1 MAJ Andrew D. Fisher is a general surgery resident at the University of New Mexico School of Medicine, Albuquerque, NM, and is a physician
assistant with the Texas Army National Guard, Austin, TX. CPT Joseph Jude is affiliated with Carl R. Darnall Army Medical Center, Depart-
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ment of Emergency Medicine, Fort Hood, TX. LTC Michael D. April is affiliated with the Uniformed Services University of the Health Sciences,
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Bethesda, MD, and is Commander of the 14th Field Hospital, Fort Stewart, GA. Jason Lavender is a student at Colby College, Waterville, ME.
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5 Xander S. Augustson is a medical student at the University of New Mexico School of Medicine, Albuquerque, NM. CPT John C. Maitha is
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trauma-critical care physician assistant at the Cooper University Hospital, Camden, NJ. LTC Steven G. Schauer is affiliated with the Uniformed
Services University of the Health Sciences, Bethesda, MD, and the Departments of Anesthesiology and Emergency Medicine and the Colorado
Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO.
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