Category Archives: General

Serial Hemoglobin To Monitor Chest Tube Output? Huh?

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:

  • What is the Hgb or Hct of the fluid coming out of the chest tube? At worst, it will be the same as the patient, assuming that pure, whole blood is coming out. But this is seldom the case. The fluid is usually described as “serosanguinous”, which is not very exact, but tells you that it is thinner than blood. And if it looks more like Kool-Aid, the concentration is very low indeed.
  • What is the volume in the container? Most collection systems will collect a maximum of 1 to 1.5 L of juice.
  • How fast is it coming out? These things almost never fill right in front of your eyes. It’s a slow process, with less than a few hundred ccs per shift.

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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Blood Transfusion With Component Therapy vs Whole Blood

About 40 years ago, blood banks started moving away from keeping whole blood and began separating it into components (packed cells, platelets, plasma, etc.) for more targeted use. For most uses, this is just fine. But what about trauma?

Trauma patients bleed whole blood. Doesn’t it make sense to give whole blood back? Much of our experience with massive transfusion is derived from our colleagues in the military. Two decades ago, the norm was to give 4 units of packed red cells or so, then give two units of plasma, and every once in a while slip in a bag of platelets. Our military experience seems to indicate that this 4:2:1 ratio is not optimal, and that something like 1:1:1 is better.

If you think about it, whole blood is already 1:1:1. Splitting it into components and then giving each one of them back separately seems to be a lot of extra work (and expense) to accomplish the same thing as just giving a unit of whole blood. And if you look at the purple table above, rebuilding a unit of whole blood from components isn’t nearly as good as whole blood. Plus it triples the exposure to infectious agents and antigens, since the components will usually come from (at least) three separate donors. Note that the data in the table above is true for fresh whole blood (not practical in civilian life); banked whole blood will still lose some coagulation activity. 

Is it time to think about supplying whole blood to trauma centers? And actually looking at whether the outcomes are better or not?

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Advanced Needle Thoracostomy

In the past, I’ve written about the merits of needle vs finger thoracostomy. One of the arguments against needle thoracostomy is that it may not reach into the chest cavity in obese patients. As I mentioned yesterday, use the right needle!

Obviously, the one on top isn’t going to get you very far. The bottom one (10 gauge 3 inch) should get into most pleural spaces.

But what if you don’t have the right needle? Or what if the patient is massively obese and the longer needle won’t even reach? Pushing harder may seem logical, but it doesn’t work. You might be able to get the needle to reach to the pleural space, but the catheter won’t stay in it.

Here’s the trick. First, make the angiocatheter longer by hooking it up to a small (5 or 10cc) syringe. Now prep the chest over your location of choice (2nd intercostal space, mid-clavicular line or 5th intercostal space, anterior axillary line) and make a skin incision slightly larger than the diameter of the syringe. Now place the syringe and attached needle into the chest via your incision. It is guaranteed to reach the pleura, because you can now get the hub of the catheter down to the level of the ribs. Just don’t forget to pull out the catheter once you’ve placed the chest tube!

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The Right Way to Treat Tension Pneumothorax

Tension pneumothorax is an uncommon but potentially lethal manifestation of chest injury. An injury to the lung occurs that creates a one-way valve effect, allowing a small amount of air to escape with every breath. Eventually the volume becomes so large as to cause the lung and mediastinum to push toward the other side, with profound hypotension and cardiovascular collapse.

The classic clinical findings are:

  • Hypotension
  • Decreased or absent breath sounds on the affected side
  • Hyperresonance to percussion
  • Shift of the trachea away from the affected side
  • Distended neck veins

You should never diagnose a tension pneumothorax with a chest xray or CT scan, because the diagnosis is a clinical one and the patient may die while these procedures are carried out. Having said that, here’s one:

image

The arrow points to the completely collapsed lung. Note the trachea bowing to the right.

As soon as the diagnosis is made, the right thing to do is to “needle the chest.” A large bore angiocath should be placed in the second intercostal space, mid-clavicular line, sliding right over the top of the third rib. The needle should then be removed, leaving the catheter.

The traditional large bore needle is 14 gauge, but they tend to be short and flimsy. They may not penetrate the pleura in an obese patient, and will probably kink off rapidly. Order the largest, longest angiocath possible and stock them in your trauma resuscitation rooms.

image

The top catheter in this photo is a 14 gauge 1.25 inch model. The bottom (preferred at Regions) is a 10 gauge 3 inch unit. Big difference! 

The final tip to treating a tension pneumothorax is that a chest tube must be placed immediately after inserting the needle. If the patient is on a ventilator, the positive pressure will slowly expand the lung. But if they are breathing spontaneously, the needle will change the tension pneumothorax into a simple open pneumothorax. Patients with other cardiovascular problems will not tolerate this for long and may need to be intubated if you dawdle.

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How Big Should Your Trauma Bay Be?

Trauma resuscitation rooms vary tremendously. They can range from very spacious…

to very tight…

Most trauma bays that I have visited were somewhere between 225 and 300 square feet (21-28 sq meters), although some were quite large (Rashid Hospital in Dubai at nearly 50 sq meters!).

Interestingly, I did manage to find a set of published guidelines on this topic. The Facility Guidelines Institute (FGI) develops detailed recommendations for the design of a variety of healthcare facilities. Here are their guidelines for adult trauma bays:

  • Single patient room: The clear floor area should be 250 sq ft (23 sq m), with a minimum clearance of 5 feet on all sides of the patient stretcher.
  • Multiple patient room: The clear floor area should be 200 sq ft (18.5 sq m) with curtains separating patient areas. Minimum clearance of 5 feet on all sides of the patient stretcher should be maintained.

The FGI “clear floor area” corresponds to my “Trauma Bay Working Area”, which is the area that excludes all the carts, cabinets, and countertops scattered about the usual trauma room. California’s guideline of 280 sq feet seems pretty reasonable as the “Trauma Bay Total Area”, if you can keep your wasted space down to about 30 sq feet.

Bottom line: Once again, don’t try to figure out everything from scratch. Somebody has probably already done it (designed a trauma bay, developed a practice guideline, etc). But remember, a generic guideline or even one developed for a specific institution may not completely fit your situation. In this case, the FGI guidelines say nothing about the trauma team size, which is a critical factor in space planning. Use the work of others as a springboard to jump start your own efforts at solving the problem.

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