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Thoracictrauma: Which Chest Tube When and Where?
Thoracictrauma: Which Chest Tube When and Where?
KEYWORDS
Chest trauma Traumatic hemo/pneumothorax Emergency surgery Mass casualty Triage
KEY POINTS
Penetrating and blunt trauma (with or without rib fracture) needs different tactics according to
mechanism of injury.
Selective conservativism and drainage surmounted pleural space control are dominating optimally
invasive chest trauma management.
Massive bleeding and/or trapped intrapleural air causing high intrathoracic pressure are the 2 main
catastrophic but potentially survivable events, in which decompression by a drain offers a simple
and efficient solution in 90% to 95% of all cases.
Many failed but still existing dogmas and misunderstandings surrounding hemo/pneumothorax, ill
interpretation of “horror vacui pleurae,” prevents a more proactive surgical attitude toward this
method among nonthoracic surgeons and allied specialists.
Experience-based convictions and received wisdom prevails as only a limited number of statisti-
cally controlled evidence exists.
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Thoracic Trauma 15
drainage, whereas on the other hand, the agreement on the optimal location of the chest
symptom-free patients with a stab wound whose drainage,23 a rare exception, as so many divergent
pneumothorax is smaller than 2 cm, also can opinions coexist on this topic. The patient is lying
wait.18 There are opinions for a (nearly) immediate in a mild head-up position (anti-Trendelenburg or
discharge of asymptomatic penetrating trauma Fowler position) with the affected side up. The
cases, with negative CXR,13 whereas others are midaxillary or the anterior axillary line offers an
a little bit more cautious. Physiologic parameters ideally thin layer of the chest wall muscles and
and imaging are steering the decisions less the fifth or sixth intercostal spaces (between the
aggressively in cases of blunt thoracic injuries usu- fifth and sixth or sixth and seventh ribs, respec-
ally complicated by rib/sternum fracture.5,14 tively) are mentioned more frequently.24,25 Go
Drainage of the pleural space has to have defin- lower in this safe triangle and you might find your
itive aims, but surgical correction of a radiologic tube in the abdomen or just too close to the dia-
picture is not one of them. Pneumothorax less phragm; or go higher and the subpulmonary region
than 10% or 2 cm and symptomless does not of the pleural space will be left without effective
require a chest drain.18 However, these patients evacuation. Chest tubes do not need to be
need to be monitored for at least 24 hours.19 It is directed posteriorly,26 but an upward position is
worth remembering that for more than 60 years, advantageous. The above site recommendation
pneumothorax was induced artificially as a sole is true in the relatively rare cases of thoracic mono-
treatment in the hope of cure of tuberculosis; so trauma. The advice loses its relevance when either
a limited amount of intrapleural air does not cause a polytrauma patient is treated by a team or preho-
any harm. The military surgical experience during spital resuscitation is performed.27 Where a multi-
World War I saw benefit of air replacement of the trauma or polytrauma patient in a supine position
tapped hemothorax,20 a common procedure for is considered, and the primary survey is under
lung tuberculosis in the age. What is obvious in way, there are 2 choices of drain sites. One might
contemporary practice is that preinjury inherent re- follow the axillary route, detailed previously, or an
serves of the ventilatory capacities are decisive in anterior approach in which the second or third
the outcome. intercostal space is entered. The former might be
Hemothorax is a different case, in which amount somewhat uncomfortable for the surgeon from
of original volume and tendency commands a an ergonomic point of view, whereas the latter is
different approach.14,21 Any hemothorax respon- complicated by the stout pectoral muscle mass.
sible for ventilatory compromise needs to be No other evidence than massive expert opinion
drained immediately. and common sense support the practice.
An open pneumothorax (sucking chest wound),
in which the pleural space is in a definite and per- What
manent continuation with the surrounding atmo-
The size of tube and of hemothorax to be evacu-
spheric environment (permanent hole, destroyed/
ated are equally important determinants.5,28 The
missing full-depth chest wall, sucking chest
material of the drain has an utmost importance,
wound) needs a secure cover and a drain. Alterna-
as it must be flexible and resilient but should resist
tively, dressings/covers with a built-in 1-way valve
the compression in the intercostal tunnel and intra-
are available (SAM [Vented; SAM Medical Prod-
pleural kinking. Silicon, an ideal component for
ucts, The Netherlands, The Hague], HALO [Halo
soft abdominal drains, is unsuitable above the dia-
VENT Chest Seal; Halo Automotive, USA], Asher-
phragm. Unrevealed occluded chest drains are
mann Chest Seal [Teleflex Medical, Coventry,
deceiving to the surgeon, suggesting patency
CT, USA], Bolin [H&H Medical Corporation, Wil-
falsely. The tubes must be multiholed and should
liamsburg, VA, USA], and Russell Chest Seal [Pro-
be marked for CXRs. As far as size is concerned,
metheus Medical Ltd, Hope Under Dinmore,
there is a general agreement on the recommenda-
Herefordshire, UK] and other models based on
tion of between 28 and 30-French gauge (Ch) for
slightly different concepts). No independent
an average adult and larger for larger body and/
comparative study is available on their perfor-
or massive hemothorax. A smaller diameter might
mance in the clinical setting.22
work in selected cases, pigtail is not excluded,29
and a more flexible approach is permitted where
Where pure pneumothorax is concerned.30
The side of pneumothorax/hemothorax should be
How
marked before the procedure, the CXR/CT/Chest
ultrasound consulted and communicated to the Obtain written consent of the patient if applicable
staff, and finally checked again. There is a general and available and document if not. Explain the
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16 Molnar
procedure to the patient and share your plans with Proper indication, safe technique, and close con-
the staff. Double-check the side. Surgical tech- trol after care are 3 equally important pillars of suc-
nique consists of 4 basic steps: (1) skin incision cess. Preparations include consent (bypassable
and tunneling, (2) entering the chest cavity and only in unconscious patients), local anesthesia,
introducing the drain, (3) fixing the tube, and (4) and systemic pain control during and after inter-
finally connecting it to the suction with detailed in- vention. Antibiotics are a question of debate, as
structions on how to manage the system. hard evidence that is based on observational
The skin incision should allow the maneuvering rather than randomized studies is inconsistent. A
of the tube through the chest wall and into the pooled analysis of 1234 patients revealed that
pleural space. The size of the drain defines antibiotic prophylaxis resulted in an almost 3 times
the length of the incision in less than an inch (1.5– lower risk of empyema than those who did not
2.0 cm). There are 3 methods of passing the tube receive antibiotic treatment. The infection rate
into the desired place and position. First, the oldest was reduced impressively in the subgroup of
and nowadays old-fashioned way of pleural deten- penetrating chest injuries. Blunt trauma subgroup
tion is using a trocar and introducing the drain did not benefit from antibiotic prophylaxis.34 There
through it. The second option is the application of seems to be an agreement on the need of a single-
some derivative of the mandrin, another French dose prophylactic antibiotic, in spite of growing
medical word, which is an inverted, “inside-out” concerns of antibiotic abuse and subsequent
trocar. The chest drain is pulled over a guiding multidrug resistance. Common sense also dic-
rod or thin stylet in its full length. There is an endless tates a self-restraining policy in pneumothorax
list of different ready-made single-use chest drain cases, whereas penetrating chest injuries demand
kits on the market based on the same principle: antibiotic prophylaxis.35 Skin disinfection and pain
introducing the rod-tube complex and then remove control, frequently undervalued, should be integral
the rigid inner part. All models share the same parts of proper drainage.36
disadvantage: as the tip of the complex enters The ways of securing the tube to the skin, pre-
the pleural space, no one knows exactly where it venting dislodgement, surgical emphysema, and
will end. There is no intrathoracic organ that this falling out are numerous. The simplest way is to
skewer, ideal for an open-air shashlik roasting use 2 string of ties: one for anchorage and one
party, did not perforate, according to collected for closing the wound when the tube is removed.
data and individual case reports.31–33 The method Common sense dictates using stranded cord
is recommendable only for complete and total trau- (0 or stronger), as it is less slippery than coated
matic pneumothorax and/or massive hemothorax. or monofilament surgical thread. Many of us prefer
Industrial interference on the medical device mar- 2-in-1 solutions: in which the thread is coiled
ket and surgical idleness are responsible for the around the tube in multiple rounds and is spun in
overpermeation of the technology. reverse when the tube is removed and tied as a
Blunt dissection of the subcutaneous tissue, simple wound closure. Every thoracic surgeon
then the intercostal layer using a Pean/Roberts for- has developed his or her own method, as has
ceps in a step-by-step manner, provides the the present author (Fig. 1). The traditional “Roman
safest approach to the pleural space. The index sandal” method with alpha-cross-wires37 seems
finger may complete the innermost 1 to 2 mm of to be less than ideal.38 The method has its modifi-
the tunnel and enter the chest cavity. As the tip cations39 but independent comparison results are
of the drain safely enters the pleural space, use still awaited. Insufficient securing of the tube takes
the Pean/Roberts forceps to steer it into the direc- its revenge not only in slipping out, but in surgical
tion of the apical region of the chest cage. Atten- emphysema, as well.40
tion must be paid so that the last side-hole is
well within the pleural cavity, otherwise it tends
Who
to slip out, causing surgical emphysema.
There are no comparative studies with regard to Chest drainage as an emergency procedure
the relative values of the 3 different techniques. should be performed by any manual specialists.
The authors’ nonevidenced subjective but This is a basic competence, the same as cricothyr-
educated guess is that thoracic surgeons and otomy or application of a tourniquet bandage in
many trauma specialists prefer the last method, profuse bleeding of an extremity. The local rules
whereas nonsurgical specialists, such as emer- may vary from country to country, usually dele-
gency doctors, intensive therapists, and junior gating the procedure to emergency medical doc-
staff, prefer the mandrin method. tors in a prehospital trauma setting. It might be
Chest drainage is a surgical intervention, what- said, that in an in-hospital emergency department
ever small and/or quick procedure it should be. setting, a first-come, first-serve rule is preferable
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Thoracic Trauma 17
A B C
D E
Fig. 1. Two in 1: how to fix the drain securely with a 2-in-1 stitch, which will close the wound at removal. (A–C)
Steps of securing the drain to the skin. (D, E) Steps to be taken at removal of the drain.
to waiting until a thoracic surgeon shows up. As is requiring immediate chest drainage are obvious
expected, seniority helps: complication rate, even even on rudimentary radiological means. CXR is
security of fixing ties, are closely related with expe- losing territory to CT. Emergency ultrasound
rience.32,33,38 However, this fact should not limit and e-FAST support a decision when physical ex-
junior staff activity. There is no such thing as too amination does not provide a clear yes/no answer
much training in the concept and exercise of chest for drainage. Chest CT helps, but is rarely needed
drainage. for the decision on emergency draining of the
Again, no reliable published prospective data thorax. When drainage is performed, it is a pri-
are available on this paragraph. mary diagnostic procedure with a 90% to 95%
chance that it is therapeutic as well, especially
PREOPERATIVE PLANNING if the injury involves the periphery of the thoracic
domain.
Running against time: this is a decisive feature of A patient with chest injury with traumatic arrest
primary treatment for chest trauma. The very first without cardiac output should need immediate
step of planning is establishing a diagnosis of decompression: bilateral drainage to exclude ten-
thoracic injury and confirming need of relieving sion pneumothorax. The expected “diagnosis ex
an acute pleural space–occupying progressive juvantibus” does not allow time to wait for imaging
condition. Mechanism of injury (eg, weapon, cir- studies. A patient with penetrating chest trauma in
cumstances of road traffic accident) offers impor- shock and with profound hypoxemia also needs to
tant clues for surgical decision making. Paramedic be drained in an attempt at restoring physiologic
and emergency medical service reports (written intrapleural environment.
and/or oral) and pressure marks on the skin are Chest drainage is equal or superior to video-
helpful. Scars of previous chest surgeries (ie, tho- assisted thorascopic surgery (VATS) exploration
racotomy, sternotomy) should warn the surgeon to in acute injury in terms of providing vital informa-
expect extensive intrathoracic adhesions. Previ- tion: is there a need for immediate thoracotomy
ous pleural inflammations also might pose a trap to identify the source of bleeding and control?
during insertion of the tube. Drainage can be performed without the risks and
Second to the prior physical examinations (in- time, staff consumption of general anesthesia,
spection, feeling, percussion, auscultation), basic and single lung ventilation of a completely un-
imaging is considered. The gross pathologies known patient. VATS or minimally invasive open
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18 Molnar
thoracic surgery (MAOTS) is ideal for the stabilized The chest tube is removable when no further air
patient, in an elective surgery setting, providing escape is detected. The swinging fluid in the con-
one has the anesthesia backup, proper experi- necting tube is a sign of cessation of active air
ence, and hospital budget. In most acute trauma leakage from the pleural surface. Being that 200
cases, no time is left for delicate minimally invasive to 300 mL/24-hour fluid evacuation is the univer-
procedures. Profuse bleeding blinds the camera, sally accepted threshold in case of malignant
and if not, then there was no need for VATS. pleural effusion, the same value also may orient
the surgeon in case of chest trauma. All in all, the
IMMEDIATE POSTPROCEDURAL CARE recommendations for patients with chest trauma
drainage do not differ significantly from the tasks
The final outcome is strongly dependent on post- to be fulfilled in general thoracic surgical cases.
operative care, which begins with the connection Pain control needs increased attention, even
of the chest drain to the adjacent systems. Written though the patient population is younger,
instructions for the staff (suction force, CXR frequently free of underlying lung diseases, and
schedules) help in avoiding communication break- expectations are good, especially if the poly-
down, especially as drained chest cases are trauma sufferers are excluded.
relatively rare in trauma wards/bays. Suction sys-
tems irrespective of their type (1-way valve, Heim- Clinical Results in the Literature
lich or Bülau type, passive or active suction) are
The very nature of chest trauma and the heteroge-
extensions of the pleural space. Force of suction
neity of the patient pool and causes explains the
in case of active suction is a question of local hos-
lack of publications with a high degree of evi-
pital policy. The numbers are variable between 10
dence. Declarations are ruling the field rather
and 50 cm H2O and every thoracic and trauma
than crystallized consensus. The reported results
consultant has his or her watertight reason for
are contradictory; the meta-analyses are suffering
her or his own particular practice. Suction regula-
from all sorts of bias. Chest drainage in thoracic
tors and drainage systems are discussed else-
trauma is not a topic at the present time and is un-
where in this issue. It must be stated here that
likely that it get over the top where randomized trial
the simplest system is better for the outcome.
overwrite the ruling practice. Approximately
There are computer-controlled mobile active suc-
150 years of collective memories and experience
tion devices available. Although their affordability
provide the backbone of our received wisdom.
and cost-benefit ratios are questionable, their
The reader is referred to the reference list to find
advantage of freeing the patient from his or her
the available sources. However, this shortcoming
bed is out of question. The junior staff and the
should not disappoint, but motivate the new gen-
nurses should understand the principle of suction
eration of trauma, chest, and general surgeons
applied, be familiar with the system used, and
and emergency doctors to conduct prospective,
troubleshooting must be straightforward. This is
ideally multicenter, and wherever possible, ran-
extremely important in emergency ward/trauma
domized trials on the questions exposed or not
departments where suction systems are not part
covered here.
of the daily routine, as they are in a general
An alibi comparation of uncomparable data
thoracic surgical unit/department. Regular control
would not serve the noble aim of a review on the
of the patency of the system, volume, and quality
erritory of chest drainage in thoracic trauma. Ref-
(hematocrit!) of evacuated fluid is also mandatory.
erences to complication and conversion rates are
Physical status of the chest should be checked by
useful only at the population level, and have no
the junior staff at least twice a day. Intervals of
relevance for the individual case. They can be
CXR control are questions of debate, in which pa-
used for quality control and litigation/malpractice
tient safety, diagnostic benefit, and the shadow of
lawsuits, but tell nothing to the surgeon in the mid-
a litigation case out of the blue are struggling with
dle of the night standing in a trauma bay.
each other. In the absence of any reliable guide-
line, the author’s practice is presented here. If any-
Alternatives to Chest Drainage
thing happens (drain repositioned, removed,
changed, suction tactics modified, patient’s con- Special circumstances and shortcomings in trained
dition deteriorated, serious complaints aroused) hands dictate need for alternatives to chest
an erect position CXR is requested (preferably drainage in certain situations and cases. Limitations
bedside) to check the situation and document. in competence and extremely dangerous/hostile
Documentation of all details is mandatory, and (care under fire) and contaminated environments
this is in the best interest of the staff and the favor needle decompression, preferred by the mili-
patient. tary.27 In spite of suboptimal results (mainly for too
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Thoracic Trauma 19
thick chest wall musculature), it has its own merit. POTENTIAL COMPLICATIONS/MANAGEMENT
Intrapleural relieving procedures performed by
drainage are considered universally beyond com- No intervention is without risks and chest
bat medic/civilian paramedic–level competences. drainage in trauma, typically under stress of time,
Too high frequency of insufficient on-site chest multitasking, and relative individuality of the chal-
drainage in prehospital care led to the concept of lenges is not an exception. It is not uncommon
emergency thoracostomy in ventilated patients.41 that problem solving becomes the problem itself.
More data are awaited; however, it is unclear Scapegoating does not help: one never can forget
why the axillary approach is preferred instead of that it is the trauma itself that is the origo of com-
the more obvious anterior chest wall limited size plications; surgical mistakes only follow. In an age
opening. It is quite convincing that creating an in which the pseudo culture of complaints and
escape route for trapped air/fluid in a closed Damocles’ sword of litigation hangs above us,
space, while oxygenation is maintained artificially this basic truth is too frequently forgotten. It is a
is preferable to a drain with dubious patency. misconception to suppose that all complications
are avoidable. Saying that, one has to emphasize,
that it does not exempt us from paying the utmost
When Not to Attempt to Drain the Chest at All attention and concentration during chest drainage
(Exclusion Criteria) and beyond in thoracic injury.
There are scenarios when chest drainage for All imaginable and even unimaginable types of
thoracic trauma is only a waste of time. Extensively complications of drains in chest trauma, not a
destroyed chest wall/lung or impaled objects might few with fatal outcomes, are described and many
call for immediate open surgery.42 Penetrating more never saw paper. These procedures are per-
wounds, either from a projectile or stabbing, in formed in a rush against time in a desperate situa-
the projection of the heart anteriorly or posteriorly, tion in a hope of stopping the complete fall of the
demand surgical exploration of the chest. A cardio- dominoes. A varying number and severity of com-
thoracic surgeon with capacity of an immediate plications can be avoided or at least reduced with
intervention at any time and ruling all necessity fa- proper protocols and training, but a complete pre-
cilities might decide otherwise (focused diagnos- emption is a logical impossibility. It is the trauma
tics, special monitoring devices) but generally this that kills at the end and not the attending sur-
is not the case. As a rule, suspicion of heart/great geon/emergency doctor.
vessel injury is amenable to immediate surgical As ICD is a lifesaving procedure in a great num-
intervention. An unnecessary exploration is the ber of cases, the risks cannot be balanced against
lesser evil and the judgment is always “a posteri- the benefits if the slightest suspicion for the need
ori.” A thoracic exploration is a highly survivable for ICD would arise. The only mistake is the one
procedure, whereas a missed penetrating heart or that ICD (or alternatives: ie, needle decompres-
major vascular injury is definitely not. sion, decompressive thoracostomy in an intubated
patient) was not performed when it was needed. A
missed tension pneumothorax or massive hemo-
When to Convert Chest Drainage to thorax are nonforgiving killers. The complication
Thoracotomy rate varies between 2% and 10%.32,33 Most com-
There is an ongoing wrestling with the numbers plications are minor ones, like kinking or displace-
of milliliters where the drainage/thoracotomy ment, slipping out, or surgical emphysema. Only
threshold is concerned. As usual, it is a multifac- 2% to 3% of all chest drain mistakes result in
eted, multifactorial question to answer. The key serious collateral damage, like perforation, with a
players are volume, time of evacuation, age, phys- mortality of 20% to 25%.32
iologic reserves, circumstances, and other factors
Immediate Complications
are to be considered. Thoracotomy has its own
inherent mortality of 0.25% to 0.5%. More than Vascular
1500 mL loss of blood at once or 300 mL per The process of insertion of the tube might cause
hour for more than 4 hours are the universally further bleeding by vessel injury. Intercostal artery
accepted values as indications for thoracotomy.5 and/or vein (60%–75% of all serious complica-
Unfortunately, systemic hemostatics (eg, factor tions) can suffer tangential rupture. Injury of the
VII, tranexamic acid) are usually not considered subclavian artery, either by the tip of the inserting
as adjunct to the treatment. One should keep in rod or the tube itself, is rare: 5% to 7% of all major
mind during transfusion, that what the patient is perforations. Any other intrathoracic vessel can be
losing and might need to be replaced is fresh full injured, of course. Minor vascular traumas are
blood. self-healing (the drain is tamponading), whereas
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20 Molnar
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Thoracic Trauma 21
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22 Molnar
improvised multilocular side holes can be used 6. Hodgetts TJ, Mahoney PF, Russell MQ, et al. ABC to
with acceptable effect. CABC: redefining the military trauma paradigm.
b. In a shortage of drainage systems/sucking bot- Emerg Med J 2006;23(10):745–6.
tles and prefabricated Heimlich valves, the 7. Heus C, Mellema JJ, Giannakopoulos GF, et al.
holed rubber gloves or condoms fixed to the Outcome of penetrating chest injuries in an urban
external tip of the tube provide an improvised level I trauma center in the Netherlands. Eur J
but safe 1-way valve. Trauma Emerg Surg 2015;2015:1863–9941.
c. von Bülau’s bottle can be improvised from sim- 8. Khorsandi M, Skouras C, Prasad S, et al. Major
ple jars. The patient’s drain should be con- cardiothoracic trauma: eleven-year review of out-
nected to the upper end of an underwater comes in the North West of England. Ann R Coll
tube. When another Bülau bottle is used, the Surg Engl 2015;97(4):298–303.
air-pipe tube (space above the water) con- 9. Blyth A. Thoracic trauma. BMJ 2014;348:g1137.
nected to a mouth piece and sucked by the pa- 10. Kong VY, Oosthuizen GV, Clarke DL. Selective con-
tient makes an improvised incentive spirometry servativism in the management of thoracic trauma
tool. The inhaled air should come against pres- remains appropriate in the 21st century. Ann R Coll
sure controlled by the depth of the tip of the Surg Engl 2015;97(3):224–8.
other tube positioned below water level. Length 11. Molnar TF. Current surgical treatment of thoracic em-
of the underwater part can be adjusted to the pyema in adults. Eur J Cardiothorac Surg 2007;
capacities of the patient. 32(3):422–30.
12. Kipling R. The Elephant’s Child. Just So Stories.
Available at: https://allpoetry.com/I-Keep-Six-Honest-
SUMMARY Serving-Men. Accessed September 30, 2016.
13. Seidzadeh GL, Yari A, Mayel M, et al. Observation
The Hamlethian question in chest trauma is to
period for asymptomatic penetrating chest trauma:
drain or not to drain. The answer is that drainage
1 or 3 h? Eur J Trauma Emerg Surg 2016;2016:
is always to be considered, except with an unsta-
1863–9933.
ble patient injured in the projection of the heart
14. Wells BJ, Roberts DJ, Grondin S, et al. To drain or
where straightforward surgery should be per-
not to drain? Predictors of tube thoracostomy inser-
formed, just like in obviously extensive thoracic
tion and outcomes associated with drainage of trau-
destruction. If drainage cannot control bleeding/
matic haemothoraces. Injury 2015;46:1743–8.
air escape, then an immediate open surgical
15. Mowery NT, Gunter OL, Collier BR, et al. Practice
approach should follow. Preinterventional investi-
management guidelines for management of hemo-
gations should be minimized, as detention has
thorax and occult pneumothorax. J Trauma 2011;
priority. Without strict written and regularly
70(2):510–8.
reviewed institutional protocols and continuous
16. Wilkerson RG, Stone MB. Sensitivity of bedside ul-
training, there is no chance to avoid complica-
trasound and supine anteroposterior chest radio-
tions, exposing patients to unnecessary collateral
graphs for the identification of pneumothorax after
damage and beyond.
blunt trauma. Acad Emerg Med 2010;17(1):11–7.
17. Soult MC, Weireter LJ, Britt RC, et al. Can routine
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Thoracic Trauma 23
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