Category Archives: Technique

Technique

By Request Again!: Submental Intubation

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I keep getting requests regarding this technique, so I’m reposting  this updated article today, and a video of the technique next week.

Here’s one of the weirder procedures I’ve seen in some time. Imagine that you need a definitive airway, but you can’t use the face for some reason (mouth or nose). The usual choice would be a tracheostomy, right? But what if you only need it for a few days? Typically, once placed, trachs must be kept for a few weeks before decannulation is safe.

Enter submental intubation. This technique involves passing an endotracheal tube through the anterior floor of the mouth, and then down the airway. This leaves the facial bones, mandible, and skull base untouched.

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The technique is straightforward:

  • After initially intubating the patient  orotracheally, a 1.5cm incision is created just off the midline in the submental area under the chin.
  • Using a hemostat, all layers are penetrated, entering the oropharynx just lateral to the tongue.
  • A 1.5cm incision is then made at the puncture site, parallel to the gum line of the lower teeth.
  • The ET tube is removed from the ventilator circuit, and the connector at the proximal end of the tube is removed.
  • The hemostat is placed through the chin incision again. The proximal end of the ET tube is curled into the oropharynx and grasped with the hemostat, then pulled out through the skin under the chin, leaving the distal (balloon) end in the trachea.
  • The connector is reinserted, and the tube is then hooked up to the anesthesia circuit again.
  • The tube is then secured using a stitch under the chin.

After a final position check, the surgical procedure can commence. Cool!

 

There are a number of variations on this technique, so you may encounter slightly different descriptions. The tube can be pulled at the end of the procedure, or left for a few days to ensure safe extubation, if needed.

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A small series of 10 patients undergoing this technique was reviewed, and there were no short or long term problems. Scarring under the chin was acceptable, and was probably less noticeable than a trach scar.

Bottom line: This is a unique and creative method for intubating patients with very short-term airway needs while their facial fractures are being fixed. Brilliant idea!

Tomorrow: Submental intubation – the video!

Reference: Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth 55(3):299-304, 2011.

Photo source: internet

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Technique

Chest Tube Repositioning – Final Answer

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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.
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Technique

Chest Tube Repositioning – Part 2

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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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Technique

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

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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 in my next post!

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Technique

How To: Treat A Penetrating Lung Injury

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Penetrating injuries of the lung come in two flavors: gunshot and stab. However, the end result for both is the same. They leak. And the leak is either air or blood. Having lower kinetic injury, stab wounds tend not to leak as much. Gunshots, on the other hand, can travel further through lung tissue and the higher energy causes more damage.

For the most part, managing these injuries is straightforward. The lung is essentially a sponge. Since most of it is air, the amount of damage done is much less than, say, to a solid organ. But bleeding and air leaks can be annoying in some cases, and even life-threatening in others.

Today, I’ll focus on injuries to the lung parenchyma. Here’s a basic primer on how to manage them.

  1. As always, the first decision to make is to answer the question, “do we need to go to the operating room right now?” This is always determined by unstable vital signs or symptoms that cannot be controlled with simple maneuvers like a chest tube.
  2. Next, determine if any treatment is needed at all. The initial chest x-ray will tell you a lot.
    1. Is there any air or blood at all? If so, a followup chest x-ray after a set amount of hours (I use 6) will detect any progression that needs future treatment.
    2. Is there too much blood or air? If so, insert a chest tube.
  3. Is there too much ongoing air leak or bleeding? This indicates a problem (bronchial or chest wall / pulmonary vascular injury) that needs operative treatment.

What are your options if you go to the operating room? Generally, an open thoracotomy is the most desirable, especially in the face of gunshots and major bleeding. It is fast and allows for rapid and complete exploration. VATS might be okay in a few stab wounds where the injury is thought to be limited but is still problematic.

Find the hole(s). With a single penetration, there are usually one or two holes. But there can be up to four if the wound traverses two lobes. And if is are more than one penetration, all bets are off.

Don’t poke a skunk. If a particular wound has no obvious bleeding or air bubbles, leave it alone. Save your efforts for the ones that are really a problem.

Use stapled tractotomy. Direct repair of lung wounds may lead to intra-parenchymal hematomas or air embolism. Wedge resection reduces lung volume, particular in patients with multiple injuries.

Here’s how to do it. Insert a GIA stapler through the bullet tract and fire. This will lay open the entire tract so that individual air leaks and bleeders can be individually suture ligated.

Then fully evacuate all blood from the chest and make sure there is no more bleeding. Failure to do so can result in retained hemothorax and the need for yet another operation. Insert a well-positioned chest tube to finish off the procedure.

Reference: Stapled pulmonary tractotomy: a rapid way to control hemorrhage in penetrating pulmonary injuries. JACS 185(5):467-487, 1997.

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