All posts by TheTraumaPro

Chest Tube Tips

I’ve written a lot about chest tubes, but there’s actually a lot to know. And a fair amount of misinformation as well. Here’s some info you need to be familiar with:

  • Chest trauma generally means there is some blood in the chest. This has some bearing on which size chest tube you choose. Never assume that there is only pneumothorax based on the chest xray. Clot will plug up small tubes.
  • Chest tubes for trauma only come in two sizes: big (36Fr) and bigger (40Fr). Only these large sizes have a chance in evacuating most of the clot from the pleural space. The only time you should consider a smaller tube, or a pigtail type catheter, is if you know for a fact that there is no blood in the chest. The only way to tell this is with chest CT, which you should not be getting for diagnosis of ordinary chest trauma.
  • When inserting the tube, you have no control of the location the tube goes once you release the instrument used to place it. Some people believe they can direct a tube anteriorly, posteriorly, or anywhere they want. They can’t, and it’s not important (see next tip).
  • Specific tube placement is not important, as long as it goes in the pleural space. Some believe that posterior placement is best for hemothorax, and anterior placement for pneumothorax. It doesn’t really matter because the laws of physics make sure that everything gets sucked out of the chest regardless of position except for things too big to fit in the tube (e.g. the lung).
  • Tunneling the tube tract over a rib is not necessary in most people. In general, we have enough fat on our chest to ensure that the tract will close up immediately when the tube is pulled. A nicely placed dressing is your insurance policy.
  • Adhere to an organized tube management protocol to reduce complications and the time the tube is in the chest.

And finally, amaze your friends! The French system used to size chest tubes is the diameter of the tube in millimeters times three. So a 40Fr chest tube has a diameter of 13.3mm.

Related posts:

Portable CT Scanning For Trauma Patients

I recently had the opportunity to see a portable head CT scanner in action, the CeroTom by NeuroLogica (Danvers, MA). Today, I’ll give my thoughts on this new technology.

There are 3 major considerations when evaluating portable CT scanning:

  • Patient safety, always at the forefront
  • Usefulness, also know as image quality
  • Financial viability

From a safety standpoint, portable scanning can decrease (but not eliminate) the safety hazards associated with transporting a critically ill patient out of the ICU. Road trips are associated with misplaced/displaced lines, tubes and monitors about 15% of the time. These are lifelines in some patients, and even momentary disruptions can be life-threatening. Some patients are on levels of support so high they are not transportable, so portable scanners offer an opportunity to get diagnostic imaging that would not be available otherwise.

Clinical performance is on par with standard scanners. Resolution is lower, but the diagnostic accuracy and reliability are not different compared to fixed scanners.

From a financial standpoint, use of the portable scanner works as well. The Cleveland Clinic deployed a CereTom scanner a few years ago and found that the unit paid for itself in 6.9 months. For you financial types, the internal rate of return was 169% and the 5-year expected economic benefit was $2.6 million.

Bottom line: This new piece of technology offers significant benefits to patients in the ICU who may otherwise not be able to get imaging due to safety reasons. It can also be employed in the OR on anesthetized patients, which can assist with diagnosis in patients with both abdominal injuries requiring immediate operation and concomitant head injury.

Practical notes: The CereTom is an 8-slice scanner with a 25cm field of view. The patient is moved onto a scan board which supports the head while it is moved slightly off the top of the bed to accommodate the scanner. Current scanner cost is $450,000 and attachment packages for hospital beds are $7,000. One CT technologist can operate the unit, which takes about 5 minutes to set up and 15 minutes to scan. All lines, tubes and monitors must be (carefully) moved to the side of the bed so the scanner can fit over the top.  

References:

  • The economic and clinical benefits of portable head/neck CT imaging in the intensive care unit. Radiology Manage 30(2):50-54, 2008.
  • Review of portable CT with assessment of a dedicated head CT scanner. Am J Neuroradiol 30:1630-1636, 2009.

I have no financial interest in Neurologica, Inc.

Fixation of Rib Fractures

Yesterday, I wrote about nonoperative management of rib fractures. Currently, the majority of rib fractures in this country are managed this way. During the past decade, a number of surgical rib fixation systems have been developed. The question is, when do you really need to consider this more invasive and potentially costly intervention? A review article from this hospital published earlier this year digs into the subsets of patients for whom operative management.

The Eastern Association for the Surgery of Trauma recently surveyed their own members, members of the Orthopedic Trauma Association, and a number of thoracic surgeons on the topic of operative rib fracture management. About 75% believed that operative fixation was indicated in some patients, but only about 20% or trauma surgeons and orthopedic surgeons and about half of thoracic surgeons had actually performed it.

The proposed benefits of surgical fixation are faster return of pulmonary function, fewer complications due to shorter ventilator time, shorter ICU and hospital lengths of stay, and a faster return to work. This review article found that these benefits were real when the technique is applied to select patients.

The authors found that:

  • The best indication is flail chest and respiratory failure without pulmonary contusion
  • Non-intubated patients with flail chest and deteriorating pulmonary function are also candidates
  • Reduction of pain and disability from symptomatic malunion or nonunion is a weaker indication due to sparse literature support
  • Other factors such as acute pain, open fractures, fracture repair while performing a thoracotomy for other reasons and chest wall deformity are weakly supported by the literature at best
  • There is no clear winner in the battle of hardware fixation systems

Bottom line: Operative rib fixation is indicated in patients with flail chest and pulmonary problems without significant pulmonary contusion, and in those with symptomatic mal- and non-unions. Flail chest patients benefit from early fixation, while the mal/nonunion groups should have fixation later once this condition is identified. Consideration for other indications should carefully take into account the cost, risk, and benefit to the patient. The literature is very weak in this regard, and a great deal more work is necessary to ensure that these techniques are not overused. 

Reference: Operative treatment of chest wall injuries: indications, technique, and outcomes. JBJS 93:97-110, 2011. 

Rib Fracture Management

A reader sent a query yesterday regarding treatment of rib fractures, and specifically asking about epidural analgesia. Today, I’ll try to answer those questions.

Rib fractures, with or without other injuries, are a big killer in trauma patients. This is particularly true in the elderly. Overall mortality rates range from 3% to 13%, with the most import factor being pain. So what is the best way to manage patients with rib fractures to speed their safe recovery?

It’s best to attack this problem from three different directions simultaneously: pain control, respiratory hygiene (or pulmonary toilet if you’re a pessimist), and activity management.

There are many approaches to pain management, which include:

  • Oral or IV analgesics
  • Various types of blocks (intrapleural, intercostal, paravertebral, epidural)
  • Topical agents (xylocaine patch)
  • Stabilization (surgical only; belts and straps are bad for breathing)

Epidural analgesia is usually seen as the ultimate form of pain control, and is usually recommended for patients with multiple fractures or severe pain with inadequate response to medications and blocks. Much of the literature on its use is based on ICU patients who were not injured. A meta-analysis was conducted that specifically looked at epidural analgesia results in trauma patients, and found that it did improve pain management and some pulmonary function tests. However, there did not appear to be any change in mortality, ICU or hospital length of stay, or time on a ventilator.

Respiratory hygiene may involve simple measures such as coughing and deep breathing, incentive spirometry, and even mechanical ventilation in severe cases. Activity management consists of turning, sitting in a chair, walking, and forms of mechanical chest wall oscillation.

Bottom Line: The key to rib fracture management is a systematic approach that address all three dimensions of care based on objective patient measures. One size does not fit all, so more aggressive measures are warranted for more severe injury. I’ve attached an interesting patented scoring system and management algorithm, as well as two protocols from US trauma centers that range from simple (Vanderbilt) to more complex (West Virginia University).

Please feel free to comment, and I’d be happy to look at your protocol. Please email it to me!

Related post: History of epidural analgesia

Downloads

References

  • Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 56(3):230-42, Epub 2009 Feb 11.
  • Rib Fracture Score and Protocol, US Patent #7,225,813 B2 – June 5, 2007

Trauma 50 Years Ago! Gunshot Wound Debridement

I’ve generally written a post every month reviewing an article from the Journal of Trauma exactly 20 years earlier that illustrates the history of some of the things we do now. I’m reaching further back in the past today, looking 50 years ago to the July 1961 issue of the first volume of the Journal.

Most trauma hospitals do not see many gunshots. There are exceptions, of course, in more urban areas. Much of what we’ve learned about taking care of gunshot wounds is based on experiences gained from the military during wartime. In the 15 years after World War II, many hospitals were treating civilian gunshot wounds like their military counterparts. 

A paper published in 1961 reported the current practice at a number of trauma hospitals across the US. Remember, there were no “trauma centers” at the time. These reports were from Bellevue in New York, St. Louis, Cook County in Chicago, Galveston, Columbus and others.

A total of 368 wounds were managed, and more than 300 were cared for without the wound debridement that had been the norm. The authors found that most did very well with cleansing and antibiotic treatment. They concluded that debridement was not necessary unless a vascular injury was also present. It was believed that the firearms found in civilian practice were universally low velocity weapons which did not inflict the degree of tissue damage of military weapons.

We generally follow this tenet to this day. Most handgun wounds do not need any special debridement. Rifle, shotgun and assault weapon injuries typically do, and is best carried out in an OR. Antibiotic use has decreased significantly, in many cases to a single dose of a drug that covers typical skin bacteria.

Reference: The indications for debridement of gun shot (bullet) wounds of the extremities in civilian practice. J Trauma 1(4):368-372, 1961.