Category Archives: Thorax

Retained Hemothorax Part 2: Lytics (again)

July 26, 2019 The Trauma Pro Leave a comment

Yesterday, I reviewed a small case report that was published a couple of years ago on lytics for treatment of retained hemothorax. But surely, there must be something better, right?

After digging around, I did find a paper from 2007 that prospectively looked at protocolized management of retained hemothorax, and its aftermath. It was carried out at a busy Level I trauma center over a 16 month period.

All patients with a hemothorax treated with chest tube received daily chest x-rays. Those with significant opacification on day 3 underwent CT scan of the chest. If more than 300 cc of retained blood was present, the patient received streptokinase or urokinase (surgeon preference and drug availability) daily, and rolled around in bed for 4 hours to attempt to distribute it. The chest tube was then unclamped and allowed to drain. This was repeated for 3 days, and if there was still opacification, a repeat CT was obtained. If the volume was still greater than 300 cc, the cycle was repeated for the next 3 days. If the opacification cleared at any point, or the repeat CT showed less than 300 cc, the protocol was stopped and the chest tube removed. If the chest was still opacified after 6 days, VATS was offered.

Here are the factoids:

A total of 203 patients with hemothorax were admitted during the study period and 25 (12%) developed a retained hemothorax
While a few had treatment start within 4 days, the majority did not receive lytics until day 9 (range 3 –30 days!)
The average length of time in hospital after start of lytics was 7 days, leading to a total length of stay of 18 days
92% of patients had “effective” evacuation of their retained hemothorax, although 1 had VATS anyway which found only 100 cc of fluid
16 patients had “complete” evacuation, and 5 had “partial” evacuation
There were no hemorrhagic complications, but one third of patients reported significant pain with drug administration

Bottom line: Sounds good, right? The drug seems reasonably effective, although lengths of stay are relatively long. However, streptokinase and urokinase are no longer available in the US, having been replaced with tissue plasminogen activator (tPA). This paper does a cost analysis of lytics vs VATS and found that the former treatment cost about $15000 (drug + hospital stay) vs $34000 for VATS. However, a big part of this was that the drug only cost about $75 per dose. tPA is much more expensive.

So once again, small series, longer lengths of stay, but at least nicely done. Unfortunately, the drug choice is no longer available so use of tPA tilts the balance away from lytics.

Reference: Intrapleural Thrombolysis for the Management of Undrained Traumatic Hemothorax: A Prospective Observational Study. J Trauma 62(5):1175-1179, 2007.

Thorax

Practice Guideline: Chest Tube Management (Part 2)

July 24, 2019 The Trauma Pro Leave a comment

Yesterday, I went over the rationale for developing a practice guideline for something as simple and lowly as chest tube management. Today, I’m posting the details of the guideline that’t been in use at my hospital for the past 15 years. I’ve updated it to reflect two lessons learned from actually using it.

Here’s an image of the practice guideline. Click to open a full-size copy in a new window:

Here are some key points:

Note the decision tree format. This eliminates uncertainty so that the clinician can stick to the script. There are no hedge words like “consider” used. Just real verbs.
We found that hospital length of stay improved when we changed the three parameters from daily monitoring to three consecutive shifts. We are prepared to pull the tube on any shift, not just during the day time. And it also allows this part of the guideline to be nursing driven. They remind the surgeons that criteria are met so we can immediately remove the tube.
Water seal is only used if there was an air leak at some point. This allows us to detect a slow ongoing leak that may not be present during our brief inspection of the system on rounds.
The American College of Surgeons Committee on Trauma expects trauma centers to monitor compliance with at least some of their guidelines. This one makes it easy for a PI nurse or other personnel to do so.
The first of the “new” parts of this guideline is: putting a 7 day cap on failure due to tube output greater than 150cc per three shifts. At that point, the infectious risks of keeping a tube in begin to outweigh its efficacy. Typically, a small effusion may appear the day following removal, then resolves shortly.
The second “new” part is moving to VATS early if it is clear that there is visible hemothorax that is not being drained by the system. Some centers may want to try irrigation or lytics, but the data for this is not great. I’ll republish my posts on this over the next two days.

Click here to download a copy of this practice guideline for adults.

Click here to download the pediatric chest tube practice guideline.

Thorax

Practice Guideline: Chest Tube Management (Part 1)

July 23, 2019 The Trauma Pro Leave a comment

Management of chest tubes is one of those clinical situations that are just perfect for practice guideline development: commonly encountered, with lots of variability between trauma professionals. There are lots of potential areas for variation:

How long should the tube stay in?
What criteria should be used to determine when to pull it?
Water seal or no?
When should followup x-rays be done?

Every one of these questions will have a very real impact on that patient’s length of stay and potential for complications.

We developed a chest tube clinical practice guideline (CPG) at Regions Hospital way back in 2004! Of course, there was little literature available to guide us in answering the questions listed above. So we had to use the clinical experience and judgment of the trauma faculty to settle on a protocol that all were comfortable with.

Ultimately, we answered the questions like this:

The tube stays in until three specific criteria are met
The criteria are: <150 cc drainage over 3 shifts, no air leak, and no residual pneumothorax (or at least a small, stable one)
Use of water seal is predicated on whether there was ever an air leak
An x-ray is obtained to determine whether any significant pneumo- or hemothorax is present prior to pulling the tube, and 6 hours after pulling it

This CPG has been in effect for over 15 years with excellent results and dramatically shortened lengths of stay. However, as with any good practice guideline, it needs occasional updates to stay abreast of new research literature or clinical experiences. We recognized that occasional patients had excessive drainage for an extended period of time. This led us to limit the length of time the tube was in to seven days. And we also noted that a few patients had visible hemothorax on their pre-pull imaging. These patients were very likely to return with clinical symptoms of lung entrapment, so we added a decision point to consider VATS at the end of the protocol.

I’ll share the full protocol tomorrow and provide a downloadable copy that you can modify for your own center. I’ll also give a little more commentary on the rationale for the key decision points in this CPG.

Thorax

Tension Pneumothorax From Inside The Chest: The Video

April 15, 2019 The Trauma Pro Leave a comment

This video shows what it looks like from the inside when a needle thoracostomy is inserted into the chest. Note that it takes about a minute for the lung to expand, so be patient when you insert the needle. You can also get an idea of why the needle is only a temporary measure as the inflating lung begins to kink the catheter.

Don’t ask why there was a thoracoscope in the chest with a tension pneumo in the first place, though!

Thorax

Relieving A Tension Pneumothorax: The Video

April 12, 2019 The Trauma Pro Leave a comment

Here’s a quick video detailing the proper steps to relieve a tension pneumothorax using needle thoracostomy. In my next post, I’ll provide a video link so you can see what it looks like from inside the chest!

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