Category Archives: What the heck?

What The Heck? Pigtail Catheter Chest Tube – The Answer

I previously described a trauma patient who had a pigtail type chest tube inserted with some odd CT findings after insertion:

So what is wrong in this picture? Well, the catheter has been inserted into the spleen! This can occur if it is inserted too low, or if there are adhesions between lung and chest wall or diaphragm.

How can it be avoided? Make sure that the insertion point is no lower than the 5th intercostal space. This is the level of the nipple in a male. And depending on what type of kit you use, be careful! Some are based on Seldinger technique, which would seem to be a bit safer. Others use a small trochar, which can be inserted a little too deeply at times. Note that this complication can occur with any kit, and can also occur when using a standard tube and open insertion technique.

Does a pigtail tube even work for hemothorax? There’s some debate about this. Traumatic hemothorax is not defibrinated like a medical one. Thus, there are frequently clots present which may not fully evacuate through a standard chest tube, let alone a tiny one. Thus, I don’t recommend a pigtail for acute traumatic hemothorax.

How should I manage this issue? Obviously, this tube needs to come out. And assuming that the initial indication for the tube is still present, a better one needs to be inserted. Dont’ pull it out yet! First, look at the vital signs. If there is significant bleeding and/or vitals are not normal, an immediate trip to the operating room is in order. In this case, the patient will likely lose their spleen.

If vital signs are stable, book both an interventional radiology suite and an OR. Or better yet, use a hybrid room. Have the radiologist obtain a baseline angiogram, and position a catheter in the main splenic artery. Incrementally remove the pigtail, hand injecting a small amount of contrast each time. If extravasation is noted at any time, the radiologist can then attempt to embolize. If selective embolization isn’t successful, then the main splenic artery should be embolized. If embolization doesn’t work, or vital signs deteriorate at any time, the surgeon should immediately proceed to laparotomy. Attempts at splenic salvage will probably not be successful.

Finally, insert a new, conventional chest tube using finger guidance. Don’t make the same mistake twice! And by the way, this works for pigtails in the liver, too. They are less likely to bleed significantly when withdrawn, and obviously the radiologist can only used selective embolization if they do.

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What The Heck? Pigtail Catheter Chest Tube

Here’s a case to make you think!

A patient arrives after being t-boned in his driver side door. He complains of left sided chest and abdominal pain. Chest x-ray shows a modest left hemopneumothorax. The decision is made to insert a pigtail type chest tube, and this is carried out in your trauma bay. It is uneventful, and a small amount of blood but no air is returned. The pelvis x-ray is unremarkable

The patient is then taken to CT, where an abdomen/pelvis scan with contrast is performed. This interesting slice is noted. What the heck?!

Here are my questions:

  • What is wrong in this picture?
  • How could it have been avoided?
  • Does a pigtail chest tube work for hemothorax?
  • How should this issue be managed, and where?

I’ll address these questions in my next post, and more!

Image source: internet

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What The Heck? CT Imaging Problem: The Answer

I received some good guesses about this image yesterday, but no one got the right answer.

The patient had sustained blunt trauma and was undergoing CT imaging. The scout for the abdominal CT showed some kind of weird debris that interfered with the image, but when we uncovered and looked at the patient, nothing was visible:

What the heck? If you look carefully at the left side of the image, you can see that the “debris field” is on the surface of the patient. We can’t see in 3-D on images, but the difference in appearance on the left and right sides looks like it this stuff is wrapping around the patient.

She was brought in by EMS with a warming blanket in place. On closer inspection, this was a thin, disposable blanket that heats up when removed from an airtight plastic pouch. These blankets contain thin pockets of a mineral mixture that looks like gravel. When exposed to air it heats up.

But on CT it looks like bone density material! When we looked at the patient, we were just lifting off the blanket that contained the offending material. Hence, we couldn’t find it.

Here’s a picture of one of these products. Note the six mineral pouches embedded in it., Don’t let this happen to you!

 

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What The Heck? CT Imaging Problem

Here’s one for you. A patient is brought to you after a motor vehicle crash. You’ve completed your evaluation in the trauma resuscitation room, and you move off to CT for some imaging.

As the techs are preparing to do the abdominal CT, they perform the scout image to set up the study. This is what you see:

The arm was left down due to a fracture (note the splint along the forearm). But what is all that debris on the image? Other than a few abrasions here and there, nothing is visible on the skin in those areas.

What the heck? What do you think these are? Will they interfere with imaging? And what can you do about it?

Tweet or comment with your answers. I will explain all tomorrow.

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What The Heck? Final Answer: Progressive Back Pain After Heavy Lifting

In my last two posts, I described an athlete who developed significant pain in his lower back after rapidly escalating his weight lifting regimen. The pain was very localized to the paraspinal areas bilaterally, and serum CPK was elevated.

Congrats to Jay Slutsky for being the first to figure this one out. The suspected diagnosis was lumbar paraspinous muscle compartment syndrome. Compartment pressures were measured, and were found to be 78 and 26 mm Hg. A contrast MRI was obtained that showed swelling of both sets of paraspinal muscles.

The patient was taken to the OR for fasciotomy.Source: Published paper

Note the bulging musculature above. Some areas appeared to be necrotic and did not bleed or contract. There were sharply debrided. The patient recovered quickly, with significant pain relief. The skin incisions were closed after several days, once swelling had subsided. He was well-healed and pain-free at his one month postop visit.

As you can see, any muscle surrounded by a rigid fascial compartment can develop a compartment syndrome. Typically, this requires direct trauma, but exertional compartment syndromes as in this case have been described in the legs of athletes as well. A history of a blow to the muscle group, or of very intense exercise should raise suspicion.

Physical findings of extreme pain that is very focal, coupled with discrete tenderness and firm muscle compartments, should confirm the potential diagnosis. Serum CPK is helpful for trending. Normal pressures in this muscle group tend to be in the single digits to low teens. They rise transiently during exercise, but usually return to normal shortly afterwards. “Normal” compartment pressures are not really known, so findings need to be coupled with CPK levels. Once the compartment pressure reaches the 30s, and especially if accompanied by high and rising CPKs, the syndrome is present. MRI is interesting, but not terribly helpful.

Treatment is typical for any compartment syndrome: release the muscle! A vertical incision centered over the bulging and tight muscle compartment is used. The wound is left open until swelling subsides enough to close the skin. Recovery is usually rapid, although some complain of a persistent low level of pain for a period of time. It is not known how soon these patients may resume sports or training.

Bottom line: Any patient with direct trauma or extreme exertion involving a muscle group is at risk for compartment syndrome. Physical exam, coupled with compartment pressure measurement if in doubt, are the mainstays of diagnosis. CPK levels may help in cases of uncertainty. As with any compartment syndrome, rapid diagnosis and fasciotomy is the key to preserving function and decreasing the likelihood of disability and chronic pain.

Related posts:

References:

  • Acute Exertional Lumbar Paraspinal Compartment Syndrome. Spine 35(25):E1529-E1533, 2010.
  • Lumbar paraspinal compartment syndrome. International Orthopaedics 36:1221-1227, 2011.
  • Paravertebral compartment syndrome after training causing severe back pain in an amateur rugby player: report of a rare case and review of the literature. BMC Musculoskelet Disord 14:259, 2013.

 

 

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