I’m dedicating the coming fortnight (that’s two weeks to you non-Brits) to the lowly chest tube. It’s taken for granted, but there is a lot a variability on how we insert, manage, and pull out these devices. Here’s what’s coming, starting tomorrow:
Videos on how to insert a chest tube and pigtail catheter
A video on how to pull a chest tube properly
Chest tube tips and tricks
A practice guideline for chest tube management
Troubleshooting chest tubes
Collection systems gone bad
Lateral chest x-ray for pneumothorax: waste of time?
Occasionally, patients who have had a severe brain injury but recovered relatively quickly may present with complaints of odd nail discoloration. This may involve fingernails and/or toenails. What gives?
This is actually a byproduct of repeated exams to determine the Glasgow Coma Scale score. A common way to determine the motor component is to squeeze the fingertip or toetip. I’ve seen some neurosurgeons use a pen to apply a great deal of force to the nail.
The discoloration is a resolving subungual hematoma. You may see different colors under different nails, depending on the age of the hematoma. Amaze your colleagues with your knowledge on this one!
This short (10 minute) video demonstrated the technique for inserting small chest tubes, also known as “pigtail catheters.” It features Jessie Nelson MD from the Regions Hospital Department of Emergency Medicine. It was first shown at the third annual Trauma Education: The Next Education conference in September 2015, for which she was a course director.
Please feel free to leave any comments or ask any questions that you may have.
Urgent and emergent intubation is challenging enough, but what if your patient is sporting some type of tongue piercing? Does it make a difference? Do you need to do anything differently?
Obviously, the jewelry may physically impede the process of intubating the patient, impairing visualization of structures or getting in the way of inserting the tube. It can also cause complications later down the road, such as pressure necrosis from the tube coming into contact with it.
The anesthesia literature recommends removing all oral jewelry prior to elective intubation, or declining to do the case if the patient refuses. Unfortunately, trauma professionals do not have that option when the patient needs an emergency airway.
Here are some pointers for dealing with oral jewlry:
Is the item going to impede insertion of the airway? Is it large, or obstructing the usual tube pathway? If so, remove it quickly (see below).
Sweep the tongue well to the side during tube insertion to avoid the jewelry. You may need an assistant to grasp it with gauze to keep it out of the way.
Once the airway is secured, remove the item. This takes two people! The ET tube should be moved to the side, and one person will grasp the tongue with a gauze pad and extend it. The other person can then grasp the jewelry with gloved fingers, and unscrew the ball on one side. It can then be removed and saved in an envelope.
Note: both hands must always be in contact with the jewelry at all times! It is slippery, and if the pieces are not controlled, this can happen!
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