Tag Archives: tips

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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Best Practice: Laundry Basket In The Resus Room?

How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.

There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.

So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.

And here’s the answer:

Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.

The “Dang!” Factor

This tip is for all trauma professionals: prehospital, doctors, nurses, etc. Anyone who touches a trauma patient. You’ve probably seen this phenomenon in action. A patient sustains a very disfiguring injury. It could be a mangled extremity, a shotgun blast to the torso, or some really severe facial trauma. People cluster around the injured part and say “Dang! That looks really bad!”

It’s just human nature. We are drawn to extremes, and that goes for trauma care as well. And it doesn’t matter what your level of training or expertise, we are all susceptible to it. The problem is that we get so engrossed (!) in the disfiguring injury that we ignore the fact that the patient is turning blue. Or bleeding to death from a small puncture wound somewhere else. We forget to focus on the other life threatening things that may be going on.

How do we avoid this common pitfall? It takes a little forethought and mental preparation. Here’s what to do:

  • If you know in advance that one of these injuries is present, prepare your crew or team. Tell them what to expect so they can guard against this phenomenon.
  • Quickly assess to see if it is life threatening. If it bleeds or sucks, it needs immediate attention. Take care of it immediately.
  • If it’s not life threatening, cover it and focus on the usual priorities (a la ATLS, for example).
  • When it’s time to address the injury in the usual order of things, uncover, assess and treat.

Don’t get caught off guard! Just being aware of this common pitfall can save you and your patient!

Tips For Taking Care Of CSF Leaks

The management of CSF leaks after trauma remains somewhat controversial. The literature is sparse, and generally consists of observational studies. However, some general guidelines are supported by large numbers of retrospectively reviewed patients.

  • Ensure that the patient actually has a CSF leak. In most patients, this is obvious because they have clear fluid leaking from ear or nose that was not present preinjury. Here are the options when the diagnosis is less obvious (i.e. serosanguinous drainage):
    • The “halo” or “double ring sign” is a form of pillow chromatography. The blood components separate from the CSF as they move through the pillow fabric, creating a clear ring or halo surrounding a bloody spot. This is the cheapest, fastest test and is actually fairly reliable.
    • High resolution images of the temporal bones and skull base. If an obvious breach is noted, especially if fluid is seen in the adjacent sinuses, then a CSF leak is extremely likely.
    • Glucose testing. CSF glucose is low compared to serum glucose.
    • Beta 2 transferrin assay. Don’t do it!! This marker is very specific to CSF. However, the test is expensive and results may take several days to a few weeks to receive. Most leaks will have closed before the results are available, making this a poor test.
  • Place the patient at bed rest with the head elevated. The basic concept is to decrease intracranial pressure, which in turn should decrease the rate of leakage. This same technique is used for management of mild ICP increases after head injury.
  • Consider prophylactic antibiotics carefully. The clinician must balance the likelihood of meningitis with the possibility of selecting resistant bacteria. If the likelihood of contamination is low and the patient is immunocompetent, antibiotics may not be needed.
  • Ear drops are probably not necessary. They may confuse the picture when gauging resolution of the CSF leak.
  • Wait. Most tramatic leaks will close spontaneously within 7-10 days. If it does not, a neurosurgeon or ENT surgeon should be consulted to consider surgical closure.


  1. Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol, 1997;18:188-197.
  2. Brodie HA. Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulas. Arch Otolaryngol Head, Neck Surg. 123:749-752.

Diagnostic Tip: Nail Discoloration After Severe TBI

Occasionally, patients who have had a severe brain injury but recovered relatively quickly may present with complaints of odd nail discoloration. This may involve fingernails and/or toenails. What gives?

This is actually a byproduct of repeated exams to determine the Glasgow Coma Scale score. A common way to determine the motor component is to squeeze the fingertip or toetip. I’ve seen some neurosurgeons use a pen to apply a great deal of force to the nail.

The discoloration is a resolving subungual hematoma. You may see different colors under different nails, depending on the age of the hematoma. Amaze your colleagues with your knowledge on this one!