2020 fun with thoracostomy's
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Presentation for ISU PARM 2223 Paramedic Course
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2020 fun with thoracostomy's
- 1. Fun with Thoracostomy's Steve Cole PARM 2223 Spring 2020
- 2. Objectives and learning outcomes Describe the normal anatomy of the chest. Explain the changes that occur in the thoracic cavity during breathing. identify abnormal conditions requiring the use of chest drainage. discuss the features of the traditional three-bottle chest drainage system. Compare and contrast needle thoracostomy, simple thoracostomy and tube thoracostomy Compare and contrast the traditional three-bottle chest drainage system with the self-contained disposable chest drainage units available today. Recognize steps in setting up a chest drainage system. Outline key aspects of caring for a patient requiring chest drainage. recognize four signs indicating a chest tube can be removed. summarize the use of autotransfusion with chest drain systems.
- 3. Anatomy and Physiology Review
- 5. Mediatinum By Mikael Häggström - Own work, CC0, https://commons.wikimedia.org/w/index.php?curid=60339025 By Grays Anatomy
- 6. Lungs
- 9. Two Categories that Require Thoracostomy Non Traumatic Rupture of the surface of the lung Rupture of the tracheal-broncheo tree Development of fluid in the pleural space Traumatic Penetration of the chest wall opening it to outside atmosphere Penetration of the chest wall that also penetrates the surface of the lung Traumatic rupture of the tracheal-broncheo tree Blunt trauma to the chest resulting in rupture of the surface of the lung Escape of air or blood into the pleural and subcutaneous spaces
- 10. Sucking Chest Wound video
- 12. Treatment
- 13. Better Question: Does it matter right NOW? 3 or 4 sides, does it matter?
- 14. Chest Seals Many types Halo SAM Bolin Asherman H and H Improvised Petroleum Gauze Defib Pad Cellophane
- 15. Hyfin Chest Seal
- 16. Better Question: Does it matter right NOW? 3 or 4 sides, does it matter?
- 17. Chest Seals Many types Halo SAM Bolin Asherman H and H Improvised Petroleum Gauze Defib Pad Cellophane
- 18. Hyfin Chest Seal
- 19. Indications Contraindications Suspected diaphragmatic rupture with protrusion of bowel into chest cavity. Suspected tension pneumothorax is evidenced by: Signs of hypoxia / respiratory distress with decreased LOC with indications below. a. Absent breath sounds over affected side b. Hyper-resonance over the affected side c. Distended neck veins d. Tracheal shift away from affected side e. Hypotension f. Trauma arrest / PEA g. Significant mechanism of blunt or penetrating chest trauma with any of the above h. JVD i. Intubated patients who become suddenly unstable or difficult to bag despite suctioning j. Patients with known rib fractures and SQ emphysema k. Other chest injuries including open chest wound(s), simple pneumothorax contusion, and flail chest. Needle chest Decompression Needle Chest Decompression both supports respirations, and also helps treat obstructive shock.
- 20. KEY POINT: “Consider underlying causes of Traumatic cardiac arrest and treat accordingly simultaneously with chest compressions. “
- 21. Needle Decompression Location The second intercostal space at the midclavicular line The fifth intercostal space, anterior midaxillary line. Remember “Air rises”
- 23. Inside view of decompression https://www.youtube.com/watch?v=co9_RLN78IY
- 24. Right Needle?* * For Adults (> 13 years of age)
- 26. REMEMBER: Right Location? Right Length of Needle?
- 27. 2019 Study of pediatric chest diameter and anatomy recommends: • Standard IV Caths instead of “long” caths except in morbidly obese. • Ages < 3: 4th IC Mid Ax (At the 2IC the heart may be pierced) • Ages >3: 2nd IC “safer” than 4th IC What about Pediatric Decompression? Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography. Prehosp Emerg Care. 2019 Jan 9:1-10. doi: 10.1080/10903127.2019.1566422. [Epub ahead of print]
- 28. Most common mistakes (Mid Ax) Location too low Needle too short Waiting too long Not re-darting Most common mistakes in chest decompression (Mid Ax) Location too low Needle too short Waiting too long Not re-darting
- 29. Problems with NCD Anterior Approach is not Where You Think it is Emerg Med J 2003;20:383-384 ED Docs got it wrong a lot! (Emerg Med J 2005;22:788) Use the Lateral Approach if you are going to do Needle Thoracostomy ANZ J Surg. 2004 Jun;74(6):420-3 Study says Anterior is closer, but (the patients had their arms in the air…do we do this in the prehospital arena? (Acad Emerg Med 2011;18:1022) Even if you get it right, Cannula may kink, occlude, or compress Scott Weingart. Podcast 62 – Needle vs. Knife II: Needle Thoracostomy?. EMCrit Blog. Published on December 11, 2011. Accessed on February 27th 2020. Available at [https://emcrit.org/emcrit/needle- finger-thoracostomy/ ].
- 31. “Traumatic Arrests are futile” – Almost everyone, everywhere… “Traumatic Arrest is not Dismal until Tension Pneumo is Ruled Out, the pelvis is wrapped, bleeding is controlled, and the airway is secured” (Paraphrased from….) Scott Weingart John Hinds Cliff Reid Almost anyone , anywhere who knows their medicine and doesn’t have their head up their ass. But it has to be done EARLY in the arrest…. Why Bother?
- 32. John Hinds experience …. 50% blunt Trauma Arrest Survival Bundle of care of “Meaningful interventions performed by a well drilled team”
- 33. Simple thoracostomy Indications: Simple thoracostomy may only be performed on patients with traumatic cardiac arrest with known or suspected injury to the chest and/or abdomen. Simple thoracostomy contraindications: Simple thoracostomy is not to be performed on patients who: Have cardiac output or blood pressure; Suffered devastating head trauma; Have blunt thoracic trauma with no witnessed cardiac activity; or Have loss of cardiac output for greater than 10 minutes. General Guidelines (consensus, not hard and fast)
- 34. Who can do them?
- 35. “Prehospital treatment of traumatic pneumothorax by simple thoracostomy without chest tube insertion is a safe and effective technique.” (Massarutti et al., 2006) “Following use of a simple thoracostomy as an alternative to chest drain insertion in 45 patients at the roadside, this technique appears to have important advantages over conventional techniques and warrants further clinical evaluation.” (Deakin et al., 1995) “ITLS believes that there is sufficient evidence to support the use of simple (finger) thoracostomy in traumatic cardiac arrest. During the immediate resuscitation of the arrest patient, consideration should be given to a bilateral simple thoracostomy. The procedure has been shown to be quick, safe, and more effective than the alternative” (ITLS, 2017) Our data show that properly trained paramedics in ground-based emergency medical services were able to safely and effectively perform ST in patients with traumatic cardiac arrest. (Dickson et al., 2018) What does the literature say?
- 38. Types of chest tubes Basically classified according to size and method of insertion Large Bore (> 20 French) Placed by Blunt Dissection Techniquew Small Bore (< 20 French) Placed by Seldinger technique
- 39. Types of Drainage Occlusion Chest tubes may be clamped and occluded for very short, emergent transports. Gravity Drainage (i.e. Pleurovac): Collection receptacle must be kept below level of the chest to prevent drained fluid from re-entering the pleural space. Do not allow the collection receptacle to tip over. Mechanical Suction Drainage: By Idaho Emergency Medical Services Physician Commission (EMSPC) standards, transport of a patient with a chest tube connected to powered suction is a critical care skill, unless being transferred under the Time Sensitive Emergency (TSE) clause. Otherwise, without specialty personnel present and assisting the EMS crew, the patient should be transitioned to gravity drainage prior to transport or occluded. If mechanical suction drainage, the amount of mechanical suction must be specified. Mechanical suction rate should remain constant during the transport.
- 40. One Bottle System One-bottle system simplest set up first tube submerged in 2 cm water creates a water seal second tube connected to wall suction excessive accumulation of fluid can cause decreased function of the unit
- 41. Two Bottle / Chamber System Separate bottles for collecting drainage and for the water seal air from the pleural space travels from the collecting bottle to the water seal bottle and exits into the atmosphere separate bottle for drainage means more fluids can be collected before a new bottle is needed
- 42. Three Chamber Separate bottles for collecting drainage, for the water seal, and for suction control level of fluid in the suction control bottle determines the amount of suction provided rarely used due to bulkiness
- 43. Heimlich valve
- 44. Commercial Multi- Chamber system Plastic Multi-Chamber System Commercially available Incorporates the three bottle system into one unit
- 45. Wet vs. Dry? Three-chamber system using a wet (A) or dry (B) suction mechanism. Note the drainage (d), water seal (b), and suction (a) chambers. An air leak meter indicates the degree of air leak, measured in columns from 1 to 5 (wet system) or 1 to 7 (dry system).
- 46. Always keep handy…. Sterile normal saline Used If tubing gets disconnected submerge the end of the chest tube (1 to 2 inches or 2-4 cm) below the surface of sterile normal saline to establish a water seal, allowing air to escape and preventing air from re-entering Chest Seal used to cover the chest incision if the tubing is accidently removed allows air to escape from the incision, and prevents air from entering the incision
- 47. Keep lower than the patient
- 48. Patient Deterioration? Think DOPES Respiratory: Any signs of increased respiratory distress New onset or worsening crepitus Signs of a clogged chest tube (blood clot in tube) Increased respiratory Rate Circulatory Hypotension Hypovolemic shock Increased Tachycardia Other Any signs of increased air leakage Greater than 100 cc of drainage in one hour for two or more hours Fever DISPLACEMENT Tube pulled out OBSTRUCTION Clogged Drainage tube PNEUMOTHORAX It can still happen EQUIPMENT FAILURE Check your drainage system STACKED BREATHS Ventilator Malfunction?
- 49. Questions?
Editor's Notes
- The Mediastinum and Its 3 Main Regions. The mediastinum is an important region of the body located between the lungs. Structures that lie in this region include the heart, the esophagus, the trachea, and large blood vessels including the area. The mediastinum is also home to lymph nodes. The mediastinum (from Medieval Latin mediastinus, "midway"[2]) is the central compartment of the thoracic cavity surrounded by loose connective tissue, as an undelineated region that contains a group of structures within the thorax. The mediastinum contains the heart and its vessels, the esophagus, the trachea, the phrenic and cardiac nerves, the thoracic duct, the thymus and the lymph nodes of the central chest.
- each of a pair of serous membranes lining the thorax and enveloping the lungs in humans and other mammals
- Questions to ask: What else would have been a better dressing to use? What could have been done better to seal the wound?
- From TECC: “b) All potential open and/or sucking chest wounds should be treated by immediately applying a manufactured vented or improvised taped occlusive seal to cover the defect. c) Monitor the injured person for the potential development of a subsequent tension pneumothorax (symptoms include progressive difficulty breathing, agitation, and/or breathlessness in a patient who has penetrating torso trauma)…” Point out how the use of a commercial chest seal device is imperitive due to patient being diaphoretic and really bloody.
- From TECC: “b) All potential open and/or sucking chest wounds should be treated by immediately applying a manufactured vented or improvised taped occlusive seal to cover the defect. c) Monitor the injured person for the potential development of a subsequent tension pneumothorax (symptoms include progressive difficulty breathing, agitation, and/or breathlessness in a patient who has penetrating torso trauma)…” Point out how the use of a commercial chest seal device is imperitive due to patient being diaphoretic and really bloody.
- Needle Chest Decompression both supports Respirations, but also helps treat Obstructive Shock.
- Protocol T-05 Traumatic Cardiac Arrest: Note that it is recommended for bi-lateral needle chest decompression. From TECC: “d) If tension pneumothorax is present or developing, attempt to ‘decompress’ the pressure building up by: i) Removing and/or “burping” the chest seal ii) Communicate priority for evacuation..” NOTE: MCA on interstate 6/2018 – Trauma code in Meridian -> bilat decompression -> ROSC! With pt talking to them!
- Key Point: This study looked at providers “eyeball” judgement of proper position, and as you can see they were way off. Most providers went too low and too medial. I think this is because they judge based off of the visible part of the clavicle and not the entire clavicle. Air rises: Semi-fowlers or recumbent is preferred. This way the air rises next to point of needle insertion, creating a larger potential space.
- https://www.youtube.com/watch?v=co9_RLN78IY This dramatic video of a tension pneumothorax being relieved by a needle thoracostomy was taken by Dr. Oleksandr Linchevskyy, medical director, Patriot Defense, Ukraine.
- Cook 6 french = 14 G diameter What about a longer needle? Many catheters used for needle decompression are 5 cm in length; however, some have access to 8 cm angiocatheters. A analysis by Clemency and colleagues found that in order to achieve a success rate of 95%, we would need a catheter at lease 6.4 cm in length [8]. Similarly, Laan and colleagues conducted a pre-post retrospective study in an EMS system that switched from using 5 cm catheters to 8 cm catheters with an increase in success rate (48% vs 83%) [6]. For a life saving, last ditch effort, I'm not sure that 95% success rate is adequate when alternatives exist.
- Important structures surround the 2ICS MCL. As mentioned above, we seem to have a tough time finding the 2ICS MCL [8,9]. There are important structures in this vicinity, particularly if the tendency is to go more medial than the actual midclavicular line, including the internal mammary artery and contents of the superior mediastinum. Naturally, should an individual placing a needle in the 4/5ICS AAL go too caudal the possibility exists for the needle to enter the liver or spleen but the study by Inaba and colleagues suggest we may be better able to identify this space [9]. Given the literature, it seems that at this time should a needle be placed aiming for the 2ICS MCL for needle decompression and fail, this is a failure of education and changing our knowledge base rather than a patient-based failure. We should know better.
- Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography. Prehosp Emerg Care. 2019 Jan 9:1-10. doi: 10.1080/10903127.2019.1566422. [Epub ahead of print] Prehosp Emerg Care. 2019 Jan 9:1-9. doi: 10.1080/10903127.2019.1566422. [Epub ahead of print] Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography. Mandt MJ, Hayes K, Severyn F, Adelgais K. Abstract OBJECTIVE: Needle thoracostomy is a life-saving procedure. Advanced Trauma Life Support guidelines recommend insertion of a 5 cm, 14-gauge needle for pneumothorax decompression. High-risk complications can arise if utilizing an inappropriate needle size. No study exist evaluating appropriate needle length in pediatric patients. Utilizing computed tomography (CT), we determined the needle length required to access the pleural cavity in children matched to Broselow™ Pediatric Emergency Tape color. METHODS: Three investigators reviewed chest CTs of children <13 years of age obtained between 2010 and 2015. Patient exclusions included those with a chest wall mass, muscle disease, pectus deformity, anasarca, prior open thoracotomy, inadequate imaging, or missing height documentation. We established 4 groups based upon Broselow™ color as determined by recorded height. Investigators, trained by a pediatric board-certified radiologist, obtained standardized CT measurements of chest wall thickness at 4 points: right/left second intercostal space at the midclavicular line (ICS-MCL) and right/left fourth intercostal space in the anterior axillary line (ICS-AAL). Our outcome was the median chest wall thickness and 95% confidence intervals for each Broselow grouping and anatomic site. RESULTS: A total of 273 chest CTs were reviewed, of which 23 were excluded, for a resultant study population of 250 scans and 498 total measurements. Median patient age was 4 years, 52.8% were male. Children measuring Broselow Gray/Pink (<68 cm), had a median chest wall thickness at the 2nd ICS-MCL of 1.57 cm (95% CI 1.42 cm, 1.72 cm), 4th ICS-AAL 1.67 cm (95% CI 1.48 cm, 1.86 cm). Broselow Red/Purple (68.1-90 cm): 2nd ICS-MCL of 1.96 cm (95% CI 1.84 cm, 2.08 cm), 4th ICS-AAL 1.73 cm (95% CI 1.62 cm, 1.84 cm). Broselow Yellow/White (90.1-115cm): 2nd ICS-MCL of 2.12 cm (95% CI 2.03 cm, 1.22 cm), 4th ICS-AAL 1.91 cm (95% CI 1.8 cm, 2.01 cm). Broselow Blue/Orange/Green (>115.1 cm): 2nd ICS-MCL of 2.45 cm (95% CI 2.3 cm, 2.6 cm), 4th ICS-AAL 2.19cm (95% CI 2.02 cm, 2.36 cm). CONCLUSION: Median chest wall thickness varies little by height or location in children <13 years of age. The standard 5-cm needle is twice the chest wall thickness of most children. Commercially available 14 g or 16 g standard-length 3.8 cm (1½ inch) needles are of adequate length to access the pleural cavity, regardless of height as measured by Broselow LBT. Great Review: https://theresusroom.co.uk/papers-of-june-2019/
- Simple thoracostomy is a technique similar to the placement of a chest tube, traditionally done in the ED but gaining increasing acceptance in the tactical, HEMS, austere medical and even prehospital community. It utilizes an incision with a scalpel and penetration directly into the thoracic cavity with forceps and a gloved finger to relieve the tension pneumothorax
- GSAHEMS 1.44K subscribers SUBSCRIBED Open 'finger' thoracostomy technique for ventilated patients as taught at Sydney HEMS Team Induction training August 2015, using porcine tissue. SHOW MORE
- Generally, chest tubes divide into two size varieties: large-bore and small-bore. A large-bore chest tube is 20 Fr or larger, while a small-bore chest tube is smaller than 20 Fr. Smaller tubes are also available and are known as pleural catheters There are many kinds of chest tubes or catheters, but they are basically classified according to size and method of insertion5. Commercially available chest tubes are made of different materials, including polyvinyl chloride, polyethylene, and silicone. They can be straight, angled, or coiled at the end (“pig-tail”). They contain a number of holes along the side and the tip, and all have a radiopaque stripe with a gap that serves to mark the most proximal drainage hole (“sentinel” hole). Some tubes have a double lumen, the small one normally being used for irrigation. The internal diameter and length of chest tubes determine the air or liquid flow rate through the drain, according to the Poiseuille's law (liquids) and the Fanning equation (gases)6. The size of a chest tube refers to its outer diameter and is given in “French” (F) or “Charrière” (Ch), with 1F corresponding to one-third millimeter. Thus, a 12F tube is 4 mm in diameter. Chest tube sizes usually range between 8F and 36F (Figure 1). A general
- Occlusion o Chest tubes may be clamped and occluded for very short, emergent transports. • Gravity Drainage (i.e. Pleurovac): o Collection receptacle must be kept below level of the chest to prevent drained fluid from re-entering the pleural space. o Do not allow the collection receptacle to tip over. • Mechanical Suction Drainage: o By Idaho Emergency Medical Services Physician Commission (EMSPC) standards, transport of a patient with a chest tube connected to powered suction is a critical care skill, unless being transferred under the Time Sensitive Emergency (TSE) clause. Otherwise, without specialty personnel present and assisting the EMS crew, the patient should be transitioned to gravity drainage prior to transport or occluded. o If mechanical suction drainage, the amount of mechanical suction must be specified. o Mechanical suction rate should remain constant during the transport.
- The one-way Heimlich valve is a simple device which contains a rubber flutter valve that is occluded during inspiration (negative intrapleural and intratube pressure), thus preventing air from entering the pleural space; while being held open during expiration (positive pleural pressure) allowing the egress of air or fluid from the pleural space (Figure 3). Heimlich valves are used for the ambulatory management of pneumothorax (including patients with persistent air leaks) or tension pneumothoraces24. There are commercially available 8F catheters coupled with a self contained one-way valve and vent, which allows full patient mobility during treatment of pneumothorax (e.g., Rocket Pleural Vent).
- Three-chamber plastic units (e.g., Pleur-evac, Atrium) are probably the most commonly used Three separate chambers –Drainage collection chamber –Water seal chamber –Suction control chamber They include a collection chamber, a water-seal chamber and a suction control chamber, which are interconnected. Fluid or air drain into the collection chamber. The water-seal chamber holds a column of water (2 cm) which prevents air from being sucked into the pleural space with inspiration. Finally, the suction chamber may use a wet (water column) or a dry (valve regulator) suction mechanism that allows the suction level to be adjusted for up to −40 cm H2O for the dry device versus a maximum of −25 cm for water columns; −20 cm H2O being the typical initial pre-set level (Figure 4). This suction chamber can be attached to continuous wall (external) suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism (gravity drainage).
- Finally, the suction chamber may use a wet (water column) or a dry (valve regulator) suction mechanism that allows the suction level to be adjusted for up to −40 cm H2O for the dry device versus a maximum of −25 cm for water columns; −20 cm H2O being the typical initial pre-set level (Figure 4). This suction chamber can be attached to continuous wall (external) suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism (gravity drainage). Intermittent or constant bubbling within the water-seal chamber is indicative of an air leak, which is often more apparent when the patient coughs. Causes of bubbling other than a visceral pleural tear include a migrated tube with drainage holes outside the skin, or an inadequate closure of the chest tube insertion site. Moreover, patency of the chest tube is verified by observing respiratory fluctuations of the fluid in the water-seal chamber when the patient is on gravity drainage; no fluctuation indicates that either the tube is occluded or the lung is completely expanded and has blocked the holes of the chest tube inside the chest cavity. Swinging of the fluid in the collecting tube during respiratory cycles (“tiding”) is also characteristic of a correctly placed chest tube. Whether to apply “suction or no suction” (with “suction” meaning external suction, and “no suction” meaning water seal) is a decision to be made individually