Category Archives: General

Managing Chest Tube Air Leaks

There are a lot of opinions and not so much literature on how to manage chest tube air leaks. Here is some practical advice on how to deal with this occasional problem.

Most air leaks are an alveolar-pleural fistula, representing a connection between a very small airspace and the pleura. This should not be confused with a bronchopleural fistula, which involves larger airways and is much more challenging to manage.

First, identify what kind of leak it is. Remember, dry seal chest tube systems will not show an air leak unless it has a fluid chamber that can be filled with water (see related post below).

  • Expiratory – occurs during normal expiration only
  • Forced expiratory – occurs only with coughing
  • Inspiratory – occurs during inspiration in ventilated patients
  • Continuous

Inspiratory leaks are rare and should be managed conservatively with maneuvers to minimize airway pressures. Continuous air leaks can be monitored, but may indicate a bronchopleural fistula.

Expiratory and forced expiratory types account for about 98% of all air leaks. Small air leaks should be managed with water seal, not with increased suction. The main concept is to reduce air flow through the fistula so it can heal. A prospective study has shown that this technique stops small to moderate size leaks sooner than leaving on suction.

Larger air leaks will probably not seal on their own and are probably not safe to place on water seal. They will likely require pleurodesis, either chemical or mechanical via a VATS procedure. Blood and fibrin patches have also been tried.

Any air leak that extends hospital stay should be evaluated for appropriateness of discharge with a Heimlich valve or VATS pleurodesis.

References:

  • A prospective algorithm for the management of air leaks after pulmonary resection. Ann Thoracic Surg 66:1726-1731, 1998.
  • Prospective randomized trial compares suction versus water seal for air leaks. Ann Thoracic Surg 71:1613-1617, 2001.

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Field Concussion Testing For Athletes

Public awareness of concussions, particular those from sports, is on the rise. It’s difficult enough for trauma professionals to diagnose some of the milder forms of head injury. Expecting lay people to do this is just not realistic.

Most people have heard of ImPACT testing for head injury. This involves determining a player’s baseline ability to remember a series of words. It tests memory, attention span and reaction time. A baseline study is required, and the test takes about 20 minutes to administer using a computer.

The King-Devick test is a numerical processing tool that can be administered using an iPad or a deck of cards. A baseline value is required as well, and the test takes about 2 minutes to administer. See the video for details.

Both tests have been validated by a number of scientific studies, and both are only available for purchase. Several hospitals, trauma centers, and schools have purchased the programs and will administer them for free. 

Check out these valuable programs and consider providing them at your own local sporting events.

Links:

Related post: TBI screening with the Short Blessed Test

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New Developments On Distracted Driving

The Governors Highway Safety Association released a study that sifted through 350 scientific papers dealing with distracted driving. They summarized their analysis in a nice report that can be downloaded here.

There are 4 types of distraction:

  • Visual – looking at something other than the road
  • Auditory – listening to something not related to driving
  • Manual – manipulating something other than the steering wheel
  • Cognitive – thinking about something other than driving

Smart phones provide all four modalities! About two thirds of drivers report using a cell phone while driving, and 7-10% were observed to be using one at any given time. About 12% of drivers admit to texting while driving, and about 1% of drivers are texting at any given time. At least one driver is reported to be distracted in 15-30% of car crashes. 

The following items were gleaned from the papers reviewed:

  • Cell phone use increases crash risk, but the exact amount is not known
  • Hands-free cell phone use has not been shown to be safer
  • Texting increases crash risk, but the exact amount is not known
  • Hand-held phone bans reduce use somewhat
  • Texting bans have not shown any significant effect, although high visibility enforcement campaigns offer some hope

Syracuse NY and Hartford CT enacted high visibility campaigns (“Phone in one hand, ticket in the other”) in late 2010 and spring 2011. They found that cell phone use dropped by half, and texting dropped 72% in Hartford and 32% in Syracuse. These results do not agree with the GHSA findings, most likely because of the intensity of the efforts in these two cities. 

Bottom line: We all know that texting while driving is bad and cell phone discussions while on the road are not very good either. There may be some utility to enacting bans on these activities. However, given the other responsibilities of our police departments, enforcement will always be a lower priority. Engineering solutions like roadway rumble strips can help divert attention back to driving, and crash investigations should aggressively examine any contributions to driver distraction. Ultimately, we’re going to have to treat this problem like we do for driving while intoxicated, with stiff penalties and driving restrictions. Unfortunately, I don’t think we’ve got the fortitude to do it anytime soon.

Download: GHSA Report on Distracted Driving

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More On The EMR / Trauma Flow Sheet Debate

I’ve posted several times regarding my opinions about using an electronic medical record (EMR) system for recording trauma activations. Yesterday, I received a well thought out response that I wanted to share and comment on:

“I defy any of them to come to a trauma resuscitation and rapidly and accurately transcribe all of the information presented, or try to review a PI case based on a printed EMR report.”

I’m a nurse informaticist, I’ve been a trauma nurse for 15 years, and I review PI cases using the electronic record. I work in an inner city Level 1 trauma center that’s associated with a large academic institution. We have recently implemented an ED Information System in our department and I have documented major traumas electronically. My trauma charts beat my colleagues written flowsheet in accuracy, comprehensiveness, and detail, hands down.

Your blog entry on this topic seems very close-minded. The “flowsheet” is not the silver bullet for trauma documentation. I agree that an EMR can be lengthy but it, by far, surpasses the flowsheet in thoroughness in detail. They both have their pros and cons, why be so quick to pick one? Yes, flowsheet data might be convenient for the reviewer but have you considered the effect on workflow for the frontline staff? An ED that has a comprehensive information system (CPOE, electronic tracking, physician and nurse documentation) must pull out a piece of paper and write on it so that a reviewer can find things easier retrospectively? It seems to me the priority should be the appropriate care for the patient and positive outcomes versus a reviewer being inconvenienced by having to read a long chart.

My main problem with using an EMR to record a trauma activation is that the current human interface technology (keyboard, mouse) do not allow for rapid data entry and movement between different screens of input boxes. If a scribe such as yourself becomes extremely familiar with the system, it is certainly possible to overcome these difficulties with sheer skill. However, your response implies that you are the only one capable of doing this. Your colleagues must still use the written trauma flow sheet.

The purpose of the flow sheet is to allow any scribe to record meaningful data that can be used to document patient care and to review and rebuild a complex resuscitation for performance improvement purposes. It is not designed to please trauma center reviewers. But the process the reviewers use to reconstruct a trauma activation is the same one that the hospital’s trauma program must use to dig into the events that occur in a trauma activation. If the input data is faulty because the scribe could not keep up in the EMR or had to enter it later, or if the output is dozens of pages of data that is difficult to sift through, the trauma program manager must spend an inordinate amount of time trying to figure out exactly what happened. The “thoroughness and detail” you mention in the EMR can be a hindrance if the quantity of data eclipses its quality. I have reviewed EMR records with 30 pages in the trauma flow sheet report!

The reviewers look for some kind of trauma flow data that they can use to rapidly rebuild what happened in the trauma room. If they can’t do it, then the trauma program probably can’t do it either. Neither I nor any of the other reviewers I have worked with have found an EMR trauma flow sheet that matches the utility of paper. Yet. The day will come, but it’s not here yet.

I welcome any additional opinions on this debate. Please leave a comment!

Related post: Trauma flow sheets vs the electronic medical record and the comment below it

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ACS Review Dinner Tip: Signage

The ACS Review Dinner is an important part of gathering information on your trauma program. Many of the principal players in your program are present, and the reviewers will have specific questions for most. Although the reviewers may meet many informally before dinner begins, it may be difficult to keep all the names and titles straight.

Good signs at the table are very helpful. Here are key points on providing the best signage possible:

  • The sign must be large. Compare the size of the sign in the photo to the 8.5×11 inch document next to it.
  • The font size should be large. This allows the reviewers to read name and title from across the room.
  • The same information should be on both sides. Everyone can see their own name so they know where to sit without turning every sign around.

The sign in the photo is a perfect example of what a good placeholder should look like.

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