M. H. Parker1, A. Newcomb1, C. Liu1, C. Michetti1 1Inova Fairfax Hospital,Falls Church, VA, USA
Introduction:
Evidence to guide CT management in trauma patients is limited and tends toward thoracic surgery patients. The goal of this study was to identify current practices among trauma providers regarding trauma CT management in trauma patients.
Methods:
We designed a web-based survey (Survey Monkey) to assess CT management practices of trauma providers who were active, senior, or provisional members (N=1890) of the Eastern Association for the Surgery of Trauma via email. The survey contained multiple choice and write-in questions. Descriptive statistics were used.
Results:
The response rate was 39% (N=734). 91% of respondents were attending surgeons, the remainder fellows or residents. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with <5 years’ experience were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CT for hemothorax (HTX) and unstable patients with PTX, and larger tubes for unstable patients with HTX (Figure 1).
97.3% (PTX) and 97.5% (HTX) would place a CT to suction following placement. Most respondents (58.9%) selected transitioning to water seal after resolution of any air leak, but not before 24 hours. 25.7% would use water seal after resolution of air leak regardless of timing. For hemothorax, 41.9% of respondents would place to water seal based on a specific fluid output, 27.7% after 24 hours and 19% based on CXR findings. While CT was on suction, the majority of respondents would allow water seal for ambulation for PTX (85.0%) and HTX (93.4%). The median output at which respondents would remove a chest tube was 150cc for serosanguinous fluid and 100cc for bloody fluid. After CT removal for PTX, CXR was preferred at 4 hours (39.7%), 6 hours (21.0%) 1 hour (13.8%); 12.9% did not get a CXR.
For non-ventilated patients, most attendings chose to get CXR after placement (96.7%), prior to removal at the end of a water seal trial (69.4%) and after removal (66.1%). Some preferred CXR prior to placement to water seal (45.3%) or daily CXR (38.9%). At outpatient follow-up, only 27.4% would get a CXR for PTX. The majority (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice.
Conclusion:
Trauma CT management is variable and non-standardized, and depends mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.
