There’s lots of info out there on how to put a chest tube in. But what about on taking it out? There are a few nuances that you should be aware of so you can do this as quickly and complication-free as possible.
Have a look at this 5 minute video and let me know what you think. Please leave your comments on YouTube.
The August Trauma MedEd Newsletter will be released to subscribers on September 1. This month is the annual “Potpourri” issue. Articles include:
Anyone on the subscriber list as of midnight (CST) on August 31 will receive it the next day. Everybody else will have to wait for me to release it here the following week. So sign up for early delivery now by clicking here!
And did you catch all the malpractice articles in the last two issues?
Neurosurgeons tend to worry about aneurysms a lot. They can cause devastating and lasting neurologic dysfunction. The most common diagnostic finding, besides the classic “worst headache of my life” complaint, is subarachnoid hemorrhage (SAH). And one of the more common CT findings after head trauma is also SAH.
For that reason, CT angiography tends to get added on to the trauma workup from time to time. Trauma professionals are faced with the “chicken or the egg” question, trying to figure out if a leaking aneurysm caused the subarachnoid blood and then the fall/crash, or the fall/crash caused the blood.
A group at St. Luke’s Hospital in Bethlehem PA looked at this question using 5 years worth of retrospective data from their Level I trauma center. They noted a significant increase in the number of CT angiographic (CTA) studies being ordered in their head trauma patients and wanted to determine which patients would benefit most from this study.
Here are the factoids:
All patients who had a ruptured aneurysm had a pattern of central subarachnoid hemorrhage on CTA
Bottom line: Pre-existing aneurysms are not any more common in TBI patients than they are in the general population. However, they may be the cause of trauma on occasion. Contrary to what many think, they seem to be uncommon in cases of patients who are found down; it looks like the trauma usually comes first. However, a pattern of central subarachnoid hemorrhage is reasonably predictive of this uncommon yet dangerous problem, so addition of CT angiography of the head when it is seen on non-contrast CT appears to be warranted.
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Reference: Selected computed tomographic angiography in traumatic subarachnoid hemorrhage: a pilot study. J Surg Research, in press, 2015.
Trauma surgeons often rely on consultants to assist in the care of their patients. Orthopedic surgeons and neurosurgeons are some of the more frequent consultants, but a variety of other surgical and medical specialists may be needed. I have found that providing a set of guidelines to consultants helps to ensure quality care and provide good communication between caregivers and patients / families.
We have disseminated a set of guidelines to our colleagues, and I wanted to touch on some of the main points. You can download the full document using the link at the bottom of this post.
In order to deliver the highest quality and most cost-effective care, we request that services we consult do the following:
Bottom line: A uniform “code of behavior” is important! Ensuring good patient communication is paramount. They need to hear the same plans from all of their caregivers or else they will lose faith in us. One of the most important lessons I have learned over the years is that you do not need to implement every recommendation that a consultant makes. They may not be aware of the most current trauma literature, and they will not be familiar with how their recommendations may impact other injuries.
Click here to download the full copy of the Regions Hospital Trauma Services consultant guidelines.
I’ve already written about the (f)utility of serially monitor hemoglobin (Hgb) or hematocrit (Hct) levels when managing solid organ injury nonoperatively. What about if you are concerned with bloody output from a chest tube drainage system? Could it be of any use there?
Seems like a reasonable idea, right? Wrong. As always, think it through and do the math! Here are the questions you need to ask yourself:
Here’s a few hundred ccs of thin drainage in a collection system. Probably decrease in Hgb value – < 0.1, which is far less than the range of lab error.
Bottom line: So now do the math. Let’s say the fluid has half the hematocrit / hemoglobin of whole blood. Losing one unit (500cc) of whole blood will generally drop your Hgb by about 1 gm, or your Hct by about 3%. If the blood is half-strength like I am proposing (and the usual drainage is typically much thinner), it will take twice as much (one liter) loss to drop the lab values by that much. This will probably come close to filling up the average collection system. If it takes a day or two or more to fill up, you are not going to see much change in their lab values. And most of the time, the blood in the system is thin like Kool-Aid, so your patient is really losing very little actual blood.
So measuring serial hemoglobin / hematocrit as you watch a hemothorax drain doesn’t make sense. Unless the output is pure blood and the system is filling up in front of your eyes, of course. In that case, a trip to the OR to fix the problem might be a better idea than doing a blood draw and sitting around waiting for the result to come back.
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