Category Archives: Thorax

Practical Tip: Making Sure The Last Chest Tube Hole Is In The Chest

I recently wrote about how the completion chest x-ray can lie after insertion of a chest tube. The chest x-ray image is a 2-D representation of the patient, but you really can’t tell where the tube lies in the third dimension (front to back). That’s how a trauma professional can get suckered into thinking they just put a perfect chest tube in, when in reality they have not.

How can you be sure of the position as you are putting it in? It’s a nuisance to have to reposition it after you’ve taken down your sterile field. Here are a few suggestions, but pay particular attention to the last one. I think it’s the best.

  • Make the incision large enough so that you can visually confirm that the last hole is inside the thoracic cavity. This option is somewhat okay for thinner patients. But it leads to a larger than necessary incision, especially in patients who are obese. Not a great idea.
  • Estimate proper depth before insertion.  Hold the tube over the patient’s chest, and note the distance mark printed on the tube when the tip is placed halfway across the hemithorax (just medial to the nipple). This does take into account the amount of soft tissue on the lateral chest, but is not terribly accurate and you may accidentally contaminate the tube. The usual depth for a patient with normal body habitus is 12-14 cm at the skin. A better choice.
  • Use the “bamboo flute” technique. Once you have entered the pleural space and placed the end of the tube into it, locate and place your finger firmly over the last hole, like you were playing a flute. Keep it there as you slide the tube in until your finger contacts the ribs around the insertion point. It should be at a right angle to the chest wall. Then push it in another 2-4 cm. As long as you have performed a nice dissection down to the chest wall, this technique is close to foolproof. And double-check by making sure that the tube is at least 12-14 cm at the skin. IMHO, this is the best technique.

This is not a chest tube!

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What’s The Best Chest Seal For Sucking Chest Wounds?

The treatment of a “sucking chest wound” in the field has typically been with application of some type of occlusive dressing. Many times, a generic adhesive dressing is applied, typically the same kind used to cover IV sites. This is quick, easy, cheap, and readily available in the ambulance. But there is a danger that this could result in development of tension pneumothorax, because the dressing not only keeps air from getting in but also keeps any buildup of pneumothorax from getting out.

To avoid this, a number of vented products have been developed and approved by the US Food and Drug Administration (FDA). These devices have some sort of system to allow drainage of accumulating air or blood, typically a one-way valve or drainage channels. They also need to stick well to a chest wall, which may have blood or other fluids that might disrupt the seal completely.

The US Army has a strong interest in making sure the products they use for this purpose work exactly as promised. The US Army Institute of Surgical Research examined 5 currently FDA-approved products to determine their ability to adhere to bleeding chest wounds, and to drain accumulating air and/or blood from the pleural space. They developed an open chest wound with active bleeding in a swine model.

An open hemopneumothorax was created by infusing air and blood, the animal was stabilized, then additional aliquots of air and blood were infused to simulate ongoing bleeding and air buildup. The image below shows the 5 products used and the animal setup:

Here are the factoids:

  • Creation of the open hemopneumothorax caused the intrapleural pressure to move toward atmospheric pressure as expected, resulting in labored breathing and reduced O2 saturation
  • Sealing the wound with any of the chest seal products corrected all of the problems just noted
  • Chest seals with one way valves did not evacuate blood efficiently (Bolin and SAM). The dressings either detached due to pooled blood, or the vent system clogged from blood clot.
  • Seals with laminar channels for drainage (see the pig picture above) allowed easy escape of blood and air
  • Success rates were 100% for Sentinel and Russell, 67% for HyFin, 25% for SAM, and 0% for Bolin

Bottom line: Prehospital providers need to be familiar with the products they use to cover open chest wounds. Totally occlusive dressings can result in development of a tension pneumothorax if there is an ongoing air leak from the lung. Vented chest seals are preferable for these injuries. Just be aware that vented seals with drainage channels perform much better than those that rely on a one-way valve.

Reference: Do vented chest seals differ in efficacy? An experimental
evaluation using a swine hemopneumothorax model. J Trauma 83(1):182-189, 2017.

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Long-Term Experience With Endovascular Aortic Repair For Trauma

For decades, the treatment of blunt injury to the thoracic aorta was open repair. The big debate at the time was use of cardiac bypass vs fast clamp and sew. But starting in 1997 with the introduction of thoracic endovascular aortic repair (TEVAR) of this injury, we have rapidly moved to the point where most traumatic aortic injuries are repaired using this technique.

A report that was written nearly a decade ago indicated a relatively high complication rate for the procedure. Graft complications were reported in 18% of patients, with 14% showing endoleaks. Stroke and left arm ischemia were also reported.

The diagram above shows insertion for management of an aneurysm, but the technique is similar for trauma. Blunt aortic injury occurs closer to the left subclavian artery and care must be taken to place the endograft closer to but not covering its orifice.

As the insertion systems and stents improved, short term events have been on the decline. Unfortunately, long term followup data has been hard to come by.

Until now. An article that is not yet in print reports 11 years of experience and followup with patient undergoing TEVAR at the ShockTrauma center in Baltimore.

Here are the factoids:

  • 88 patients underwent TEVAR during the study period, all from blunt trauma
  • Average ISS was 38, showing these patients were severely injured
  • Overall mortality was 7%, but none was due to the TEVAR procedure
  • TEVAR-related complication rate was 9% Endoleaks at the ends of the graft occurred in 4 patients, and all required repair. There were 4 other minor leaks that resolved on their own.
  • 26 had all or part of the left subclavian orifice covered at initial operation. None developed ischemia, although 2 had a prophylactic carotid-subclavian bypass before TEVAR.
  • The longest followup imaging occurred 8 years after the procedure. No long-term complications were noted.

Bottom line: TEVAR has essentially replaced open repair of the aorta, except in special cases. We continue to learn from our experience, and the complication rate is still falling. Other than endoleaks recognized in the postop period, most other complications rarely occur. Long term followup is poor, but in the patients who do return, there were no complications. But remember, this is an expected sampling bias. If the patient had major problems and/or died, they would just be lost to followup. We would never know.

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What’s Wrong With My Patient? Final Answer!

I previously described a young man who was recovering from surgery for repair of a stab to the heart. He presented shortly after discharge with fever, a slightly elevated WBC, some EKG changes, and a small pericardial effusion.

Several people tweeted out the answer, which is post-pericardiotomy syndrome (PPS).

PPS is an inflammatory reaction to traumatic and then surgical injury to the pericardium. It is seen in a relatively small percentage of patients who undergo pericardiotomy for trauma, which is why patients who develop it are such a surprise to trauma professionals. A similar condition can develop after myocardial infarction (Dressler syndrome) and was first described in 1956. The classic paper describing PPS after trauma was published five years later (cited below).

Symptoms typically develop 1-6 weeks after surgery, and usually consist of low grade fevers, malaise, chest pain, and occasionally arthralgia. A pericardial friction rub may be present (and where is that stethoscope, BTW?). The WBC is usually elevated, with some degree of left shift. EKG may show some degree of pericarditis, including global ST elevation and T wave inversion.

Chest x-ray is usually nonspecific, but may show pleural effusion or an enlarged heart due to the presence of some pericardial fluid. Ultrasound may confirm a pericardial effusion, but this is not a reliable finding since the pericardium is typically left open at the end of the operation.

Treatment is symptomatic, usually consisting of NSAIDS or aspirin to tone down the inflammatory response.  These drugs are usually given for 4-6 weeks, then tapered. If the effusion is large, pericardiocentesis may be needed.

Bottom line: If your postop heart injury patient presents with these symptoms, consider infectious etiologies first, but remember that they are typically even less common than post-pericardiotomy syndrome. Reassure your patient, then reach for the ibuprofen to get them through it.

Reference: Postpericardiotomy syndrome following traumatic hemopericardium. Am J Cardiology 7(1):83-96, 1961.

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What’s Wrong With My Patient? Part 2

In my previous post, I described a young man who had recovered from a stab to the heart. He did well for a week and a half, but then presented to the ED with significant chest pain. It seems to be substernal and somewhat pleuritic. What should you do to work it up further?

There have been a number of helpful comments. The first order of business is to rule out problems which may prove to be life threatening. In his case, ischemic disease and some failure of the repair must be ruled out quickly. Although ischemia or MI are unlikely in this young man, they are possible and should be evaluated.

I recommend the following:

  • Auscultate the chest and heart (remember this from medical school?)
  • PA chest x-ray
  • EKG
  • CBC
  • Troponin
  • FAST exam focusing on the heart

My list is short and simple, and should help me figure out nearly all significant problems.

In this case, the following findings are present:

  • The lungs are clear, and their is a faint cardiac friction rub
  • The chest x-ray is unremarkable
  • EKG shows ST elevations in two of the lateral leads only. Otherwise, it is normal.
  • CBC is normal with the exception of WBC 14,000
  • There is a trace level of troponin present
  • FAST demonstrates a very small pericardial effusion without clot

So what do you make of all this? What’s the diagnosis? What do you need to do? Tweets and comments please.

Answers Monday!

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