Case: A 54-year-old male presents to your emergency department the day after being involved in a snowmobile accident on the weekend. He reports he was riding his sled along an embankment when it rolled. He thought it would get better, but the chest pain and shortness of breath have gotten worse over the past 48 hours. His vital signs are normal, and the physical exam indicates he has bruising and tenderness over the left chest wall, with diminished left-sided lung sounds. A CT scan reveals three rib fractures and a hemothorax estimated to measure 600 cc, with no additional injuries.

Clinical Question: Are small pigtail catheters (PCs) as effective as large-bore chest tubes (LBCTs) for the treatment of hemodynamically stable patients with traumatic hemothorax?

Background: Traumatic hemothoraces have been traditionally treated with LBCTs. It is important to place these in the pleural space and in the zone of safety. Whether the tube is directed up or down does not seem to be associated with outcomes.¹

A small observational study looked at 36 patients with traumatic hemothorax or hemopneumothorax receiving a PC and compared them to 191 patients receiving a LBCT. The small catheter seemed to work just as well as the LBCT.²

Reference: Kulvatunyou N, Bauman ZM, Edine SBZ, 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 and Acute Care Surg. 2021;91(5):809-813. 

• Population: Hemodynamically stable adult patients 18 years or older suffering traumatic hemothorax or hemopneumothorax requiring drainage at the discretion of the treating physician
  • Exclusions: Emergent indication, hemodynamic instability, patient refuses to participate, prisoner or pregnancy
• Intervention: Small (14 Fr) pigtail catheter
• Comparison: Large (28–32 Fr) large-bore chest tube
• Outcome: 
  • Primary Outcome: Failure rate defined as radiographically apparent hemothorax after tube placement requiring an additional intervention, such as second tube placement, thrombolysis or video-assisted thoracoscopic surgery
  • Secondary Outcomes: Insertion complication rate; drainage output (30 minutes, 24-hour, 48-hour and 72-hour); hospital course outcome up to 30 days (total tube days, ICU length of stay, hospital length of stay and ventilator days); and insertion perception experience (IPE) score (1–5 subjective score, with 1 meaning “it was okay” to 5 meaning “it was the worst experience of my life”)
• Trial Design: Multicenter, noninferior, unblinded, randomized, parallel assignment comparison trial

Authors’ Conclusions: “Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.”