Yesterday I presented the problem of the malpositioned chest tube, specifically one that is not completely in the pleural space. This one is way out:
So what do the doctor books say? Well, the first thing you will discover if you try to look it up is that THERE IS NO LITERATURE ON THIS COMMON PROBLEM! There are a few papers on tubes placed in the fissure and tubes inserted into the lung parenchyma. But there are only a few mentions of tubes with holes still outside the chest.
I’ve gotten a number of comments, including “you can push them in a little”, “take it out and put in another”, and “never push them in.” Since we don’t have any science to guide us, we have to use common sense. But remember, I’ve shown you plenty of examples where something seems reasonable, but turns out to be ineffective or downright harmful.
There are three principles that guide me when I face this problem:
- Prevention is preferable to intervention
- Do no (or as little as possible) further harm
- Be creative
Monday, I’ll finish this series and provide some tips and guidelines to help manage this problem using the principles outlined above.
The November newsletter is here! Click the image below or the link at the bottom to download. This month’s topic is Trauma Mythbusters, discussing the dogma surround and the (lack of) data supporting:
- Treating VIPs (very important people)
- Bathing and showering with a wound
- NSAIDs and fracture healing
- Rectal exam in trauma
- Contrast blush in abdominal CT in children
- Cognitive rest after TBI
Subscribers had the newsletter emailed to them on Tuesday. If you want to subscribe (and download back issues), click here.
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It happens from time to time. Your patient has a hemothorax or pneumothorax and you insert a chest tube. Well done! But then the xray comes back:
The last hole in the drain is outside the chest! What to do???
Here are the questions that need to be answered:
- Pull it out, leave it, or push it in?
- Does length of time the tube has been in make a difference?
- Does BMI matter?
Leave comments below regarding what you do. Hints tomorrow and answers on Monday!
One of the cornerstones of allopathic medicine is the use of drugs to treat disease conditions. And unfortunately, one of the side effects of using drugs to treat problems is the production of side effects(!).
In trauma care, even something as simple as treating pain from an injury can create major problems. Give a narcotic pain medication. The patient gets nauseated and vomits. Try a different narcotic. The patient develops constipation. Give stool softeners and cathartics. Diarrhea. Then pseudo-obstruction develops. Give neostigmine. The patient becomes bradycardic. Give… well, you get the picture.
How common are side effects? Very! Did anyone see the first TV commercials for Chantix, the smoking cessation drug? It was about 3 minutes long because of the long list of side effects that were described. I’m surprised anyone was willing to risk them just to stop smoking cigarettes.
A recent study looked at the number of side effects listed on the labels of 5,602 medications approved by the FDA. There were a grand total of 534,125 adverse drug effects described in the packaging. Some interesting statistics:
- The number of adverse effects for ranged from 0 to 525(!) for a single drug
- The median number of adverse effects was 49, the average was 70
- Drugs with the most side effects are used in neurology, psychiatry and rheumatology
- Newer drugs had significantly more adverse effects than older ones
It’s certainly easy to bash pharmaceutical companies on their products. But some of these findings may be due to more rigorous testing and monitoring, as well as nuances in the populations in which these drugs are used.
Bottom line: Drugs are chemicals! Each chemical has a number of effects, some of which are desirable, and some of which are not. The drug companies choose to market a drug based on one desired effect (e.g. control of nausea). Just remember, when you give that medication, you will probably get the desired effect, but you will just as likely also get some of the other 69 possible side effects. Be prepared, and prescribe sensibly.
Reference: A quantitative analysis of adverse events and “overwarning” in drug labeling. Arch Int Med 171(10):944-946, 2011.
CT scan is an invaluable tool for evaluating blunt abdominal trauma. Although it is very good at detecting solid organ injury, it is not so great with intestinal and mesenteric injuries. Older studies have suggested that CT can detect mesenteric injuries if done right, but a newly published study has shown good accuracy with a few imaging tweaks.
A Taiwanese study looked at a series of prospectively studied victims of blunt abdominal trauma. Patients with abdominal pain or a positive FAST were entrolled (total 106). IV contrast was given, and scans during the arterial, portal, and equilibrium contrast phases were performed using a multidetector scanner. Images were read in a blinded fashion.
A total of 13 of 23 patients who underwent laparotomy were found to have a bowel or mesenteric injury. Five had bowel injury, 4 had mesenteric hemorrhage, and 4 had both. Mesenteric contrast extravasation was seen in 7 patients, and this correlated with mesenteric bleeding at laparotomy.
The authors found that the following signs on CT scan indicated injury:
- Full or partial thickness change in bowel wall appearance
- Increased mesenteric density
- Free fluid without solid organ injury
Bottom line: This study shows that CT scan can detect bowel and mesenteric injury reliably if you scan the patient 3 times! This seems like over-radiation and overkill. A more intelligent way to approach this would be to perform a normal trauma abdominal scan. If a suspicious area of mesenteric or bowel thickening is seen, then a limited rescan through the affected area only for equilibrium phase images may be warranted. If actual contrast extrvasation is seen, no further scanning is needed. A quick trip to the OR is in order.
Reference: Contrast-enhanced multiphasic computed tomography for identifying life-threatening mesenteric hemorrhage and transmural bowel injuries. J Trauma 71(3):543-548, 2011.