Evaluating the Accuracy of Chest Tube Thoracostomy Site Selection by Pediatric Emergency Medicine Physicians Using Point-of-Care Ultrasound

OBJECTIVES: Chest tube thoracostomy is a core skillset within pediatric emergency medicine (PEM); however, few PEM physicians perform this procedure regularly. Site selection is typically performed through landmark identification of the fifth intercostal space (ICS), and incorrect placement can result in serious morbidity. The aims of this study were to evaluate the accuracy of safe thoracostomy site selection among PEM providers, and to identify relationships between provider demographics and experience with performance in this selection process. METHODS: This was a single-center observational study using a convenience sample of pediatric emergency department (PED) patients. Providers marked the fifth ICS bilaterally using the landmark technique, and the ICS and diaphragm levels were subsequently confirmed using point-of-care ultrasound (POCUS). Descriptive statistics were calculated for patient and provider characteristics. Associations between provider characteristics with location of the ICS mark were evaluated using a generalized estimating equation approach. RESULTS: Fifteen participating PEM providers performed 120 bilateral landmark-based ICS identifications. Among all identified sites (n=240), only 37.1% (n=89) were accurately confirmed as the fifth ICS, with 12.9% (n=31) being below the fifth ICS. Furthermore, 9.2% (n=22) of all sites were located below the diaphragm during resting breathing. Providers with longer tenure, more PED experience, greater number of chest tubes placed, and greater comfort with identifying the fifth ICS were more likely to mark below the fifth ICS (P=0.004, 0.026, <0.001, <0.001, respectively). CONCLUSIONS: This study demonstrates a considerable gap in thoracostomy site selection accuracy among PEM physicians. A significant number of chosen sites were found to be below the fifth ICS, and there was a surprising discordance between provider experience and accuracy. These findings highlight a critical gap in performance and the need for ongoing training. Incorporating POCUS into standard practice may improve site selection accuracy and patient outcomes in the PED setting.