Category Archives: Technique

Trauma In Pregnancy 7: C-Section – Technique (with video)

Your preparation. You should already have full personal protective gear on, right? Right? Your existing gear is just fine. You do not need to change to sterile gown and gloves. The time wasted is probably not worth the low risk of infection in the rare event that the mother survives.

You need at least one assistant, preferably two. They will pass you instruments and provide retraction. Continue CPR throughout the procedure.

At the same time, call your OB and neonatal colleagues, if you haven’t already. If you don’t have any at your hospital, don’t sweat it. If you do, don’t wait for them to arrive.

Patient preparation. Have someone quickly insert a foley catheter.

Do not use sterile technique. It just slows things down. The bladder needs to be empty so you can quickly and easily get to the uterus.

The procedure. Here’s the blow by blow:

  • Splash some betadine on the skin. The mother is probably not going to survive, so infection is not a concern.
  • Make a midline, vertical incision from mid-epigastrium to pubis. Extend down to the midline fascia.
  • Enter the peritoneal cavity near the umbilicus. Extend the incision along the full length of the skin incision using scissors.
  • Use the scalpel to make a 4cm vertical incision near the top of the uterus. Insert your 2nd and 3rd fingers into the uterus, directed downwards. Use them to protect the fetus from the scissors as you use them to extend the uterine incision downwards.
  • Rupture the membrane with a clamp and deliver the baby. Remember, the membrane is tough! Insert your hand deep into the lower uterus under the baby’s head. Flex the body as you gently push upwards to deliver the head first. Suction the mouth and nose, then deliver the shoulders and body.
  • Cut and clamp the cord. Hand off the baby to another team for suctioning and resuscitation.
  • Continue to try to revive the mother. If circulation is restored, move immediately to an OR for delivery of the placenta, control of the bleeding that was killing her in the first place, and hopefully, closure.

Here’s a video that shows how quickly the procedure can be done (with a few edits). Just watch the first 47 seconds!

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Chest Tube Repositioning – Final Answer

So you’re faced with a chest tube that “someone else” inserted, and the followup chest xray shows that the last drain hole is outside the chest. What to do?

Well, as I mentioned, there is very little written on this topic, just dogma. So here are some practical tips on avoiding or fixing this problem:

  • Don’t let it happen to you! When inserting the tube, make sure that it’s done right! I don’t recommend making large skin incisions just to inspect your work. Most tubes can be inserted through a 2cm incision, but you can’t see into the depths of the wound. There are two tricks:
    • In adults with a reasonable BMI, the last hole is in when the tube markings show 12cm (bigger people need bigger numbers, though)
    • After insertion, get into the habit of running a finger down the radiopaque stripe on the tube all the way to the chest wall. If you don’t feel a hole (which is punched through the stripe), this will confirm that the it is inside, and that the tube actually goes into the chest. You may laugh, but I’ve seen them placed under the scapula. This even looks normal on chest xray!
  • Patients with a high BMI may not need anything done. The soft tissue will probably keep the hole occluded. If there is no air leak, just watch it.
  • If the tube was just put in and the wound has just been prepped and dressed, and the hole is barely outside the rib line, you might consider repositioning it a centimeter or two. Infection is a real concern, so if in doubt, go to the next step.
  • Replace the tube, using a new site. Yes, it’s a nuisance and requires more anesthetic and possibly sedation, but it’s better than treating an empyema in a few days.

Related posts:

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Chest Tube Repositioning – Part 2

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

Tomorrow, I’ll finish this series and provide some tips and guidelines to help manage this problem using the principles outlined above.

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What To Do When The Chest Tube Is Not In The Right Place

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 and final answers next week!

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The Trauma Activation Pat-Down?

Yes, this is another one of my pet peeves. During a trauma activation, we all strive to adhere to the Advanced Trauma Life Support protocols. Primary survey, secondary survey, etc. Usually, the primary survey is done well.

But then we get to the secondary survey, and things get sloppy.

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The secondary survey is supposed to be a quick yet thorough physical exam, both front and back. But all too often it’s quick, and not so thorough. There is the usual laying on of the hands, but barely. Abdominal palpation is usually done well. But little effort is put into checking stability of the pelvis. The extremities are gently patted down with the hope of finding fractures. Joints are slightly flexed, but not stressed at all.

Is it just a slow degradation of physical exam skills? Is it increasing (and misguided) faith in the utility of the CT scanner? I don’t really know. But it’s real!

Bottom line: Watch yourself and your team as they perform the secondary survey! Your goal is to find all the injuries you can before you go to imaging. This means deep palpation, twisting and trying to bend extremities looking for fractures, stressing joints looking for laxity. And doing a good neuro exam! Don’t let your physical exam skills atrophy! Your patients will thank you.

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