Case from the other night--what would you have done?

[deleted9493]

Gentleman in his early 50's presents for open reduction and fixation of thoracic rib fractures 7-10 (not a standard of care) following a T-bone mechanism MVA. Small hemothorax and pneumothorax on ipsilateral side of procedure. To be in lateral position and has two 18g IVs. Hemodynamically stable and on 2L NC. Pain service placed a thoracic epidural which seemed to be working well. Other than a 30 py smoking history, dyslipidemia, and hypertension...he denies any other medical problems. Hemodynamically stable. He arrives from a floor bed and is managed by the trauma service. Before preoxygenation, his saturation is noted to be 80%

How do you proceed? I'll describe how the case evolved after a few responses and am genuinely interested in learning, as much as I am in presenting what I think to be an interesting case.

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[caligas]

Needs chest tube and note on chart explaining indication for procedure.

 

[Direct Laryngoscopy]

Is there any particular reason why rIb fractures are being surgically managed?

Anywho, what dose the PE, cxr and ABG show?

 

[anes]

Gentleman in his early 50's presents for open reduction and fixation of thoracic rib fractures 7-10 (not a standard of care) following a T-bone mechanism MVA. Small hemothorax and pneumothorax on ipsilateral side of procedure. To be in lateral position and has two 18g IVs. Hemodynamically stable and on 2L NC. Pain service placed a thoracic epidural which seemed to be working well. Other than a 30 py smoking history, dyslipidemia, and hypertension...he denies any other medical problems. Hemodynamically stable. He arrives from a floor bed and is managed by the trauma service. Before preoxygenation, his saturation is noted to be 80%

How do you proceed? I'll describe how the case evolved after a few responses and am genuinely interested in learning, as much as I am in presenting what I think to be an interesting case.

Chest tube prior to procedure (may offer some light sedation for this portion)

Prop/Sux/Tube....... Or maybe bolus with 0.5% bupivicaine or 2% lido and do the procedure with just that and a face mask.

 

[deleted9493]

Explanation for procedure: enrolled in an outcomes study for ORIF of rib fractures.

No ABG preop. Chest Xray shows mild hemothorax AND pneumothorax on operative side. Pain service had bolused 5 mL of .25% bupivacaine in preop. holding for patient comfort prior to my arrival with good effect.

PE: Normal work of breathing. Patient receiving .125% bupivacaine at 10mL/hr through T5-T6 epidural. Hydromorphone PCA with .3mg/hr basal rate and .2mg q10m PRN. Pupils 2mm and reactive. Patient mildly somnolent but oriented. No discernible difference in sidedness with lung auscultation.

 

[pgg]

How recent was the injury?

(Edit - just saw your most recent post, sounds fresh.)

 

[GhostTree]

Does he have a chest CT scan? With such an injury I imagine he might. There is probably a good amount of lung contusion on the injured side as well that is contributing to the hypoxia that won't correct with chest tube or hematoma evacuation. Still, he should have a chest tube prior to induction.

He's already demonstrating how he will handle one lung ventilation.

Does the hypoxia improve with preoxygenation?

 

[deleted171991]

(I am an ambulatory guy, so take what I say with a grain of salt.)

Sats of 80% despite O2 and good pain control? Patient not optimized for non-emergent surgery. Surgery postponed. Not fixed with chest tube? Patient intubated electively and optimized preop, taken to the OR from SICU. Are you ready to stop the surgery if, after induction, you still experience crappy sats and decide that the patient needs further optimization before OLV?

The point here is: if this is not the standard of care, the surgery is not emergent, hence the need for preop optimization. This is not a patient with severe flail chest who has failed standard treatments and needs chest stabilization; this is a medical experiment. What if both lungs are contused, and we are playing OLV on them? Are you convinced that the patient's consent, given in a post-traumatic stress situation or while "mildly somnolent" under the influence of drugs, will stand up in court?

 

[IlDestriero]

CX case.
Stat CXR to eval for progression of ptx/hemothorax +/- chest tube. If he does not respond to increased O2, intubate and off to ICU.
Spiral CT for r/o PE.
No way in hell does this guy get an elective procedure. He is not stable.

 

[IlDestriero]

10 ml/hr seems rather high for his epidural as well.

 

[dhb]

Explanation for procedure: enrolled in an outcomes study for ORIF of rib fractures.

Patient receiving .125% bupivacaine at 10mL/hr through T5-T6 epidural. Hydromorphone PCA with .3mg/hr basal rate and .2mg q10m PRN.

What kind of games are you guys playing?

 

[deleted9493]

Patient has been saturating in the mid 90's on the floor with nasal cannula. His saturations return to normal when I ask him to take a deep breath. I attribute his hypoxemia to the basal infusion of hydromorphone that the pain service continued after they placed the thoracic epidural (and had subsequently been stopped).

Injury is <48hrs old. CT shows contusion at the level of the rib fractures. Chest x-ray from earlier in the afternoon shows "mild hemothorax, mild pneumothorax". Guy is conversive, gives a good history and showing no signs of increased work of breathing.

 

[Planktonmd]

Patient has been saturating in the mid 90's on the floor with nasal cannula. His saturations return to normal when I ask him to take a deep breath. I attribute his hypoxemia to the basal infusion of hydromorphone that the pain service continued after they placed the thoracic epidural (and had subsequently been stopped).

Injury is <48hrs old. CT shows contusion at the level of the rib fractures. Chest x-ray from earlier in the afternoon shows "mild hemothorax, mild pneumothorax". Guy is conversive, gives a good history and showing no signs of increased work of breathing.

An ORIF of the ribs does not require one lung ventilation does it?

 

[Libertas]

I did a plating a few months back on a multitrauma patient with flail chest. The patient came from the ICU with a standard ETT and we did not exchange it. I believe they did very slightly/briefly violate the thoracic cavity, but we did not need a double lumen tube. I think they already had chest tubes on the side of the orif, but I don't remember for sure.

 

[deleted9493]

Surgeon said that he didn't need a double lumen tube. I wanted a chest tube and surgeon assures me that they can pop one in if any issues arise.

Induction is uneventful. Intubated and then beanbagged into lateral position. Vitals rock solid. Surgeon notices bubbling in his field and tells me "we probably should have used a DLT". I ask him to place a chest tube and he tells me that he'll wait to see if we have any problems because...well, the the bubbling has stopped and "I haven't placed one of those since residency."

I'm thinking to myself, "Great. I'm working with a surgeon who doesn't know how to manage the most likely and most immediate/dangerous complication of his own procedure."

 

[deleted9493]

By the time they were ready to start closing, patient was breathing on his own with minimal pressure support and looking like a rose. I had titrated a total of .6mg of hydromorphone over the last hour of the case according to his RR/EtCO2.

Patient emerges and is tachypneic/hypoxemic/combative...pulling his own endotracheal tube and IVs out. We call for an emergent chest tube placement. I mask him down and re-intubate him. Chest tube goes in easily and has minimal output, no leak...a little surprised. I take him to the ICU where he's extubated a few hours later uneventfully.


Were it mine to do over, I wouldn't have cancelled him but I would not have proceeded without a chest tube. Light sedation, some supplemental local and a chest tube pre-induction in the OR.

 

[IlDestriero]

Just thinking out loud, but Maybe a surgeon who can't put in a chest tube shouldn't be designing and/or participating in studies on how to manage chest trauma.

 

[OB1🤙]

Head asplode.

Wtf, man.

 

[deleted171991]

Just thinking out loud, but Maybe a surgeon who can't put in a chest tube shouldn't be designing and/or participating in studies on how to manage chest trauma.

Imagine the kind of surgeon who would do research about ORIF in uncomplicated rib fractures, that would heal nicely even on their own. It sounds almost like doing ORIF on clavicle fractures.

 

[nap$ter]

By the time they were ready to start closing, patient was breathing on his own with minimal pressure support and looking like a rose. I had titrated a total of .6mg of hydromorphone over the last hour of the case according to his RR/EtCO2.

Patient emerges and is tachypneic/hypoxemic/combative...pulling his own endotracheal tube and IVs out. We call for an emergent chest tube placement. I mask him down and re-intubate him. Chest tube goes in easily and has minimal output, no leak...a little surprised. I take him to the ICU where he's extubated a few hours later uneventfully.


Were it mine to do over, I wouldn't have cancelled him but I would not have proceeded without a chest tube. Light sedation, some supplemental local and a chest tube pre-induction in the OR.

a - i would not have done this case. if the sats are 80 preop (even if they improve with a deep breath); chest surgery ain't gonna make em better. postpone for optimization/diagnostic workup/chest tube/discontinuation and metabolism of systemic hydromorphone. elective case.

b - your surgeon is a poser - how did your partners let you get sucked into this case?

c - how did you get from green to red? of tachypnea/hypoxemia/combative which came first? how could you tell a combative patient was hypoxemic? was he cyanotic? pretty hard to get a sat on a combative patient... why did you decide a pneumo caused the progression from green to red? did you really "mask him down" ie like a peds case? or did you mean you put the mask on and gave some propofol? did a CXR show a pneumo?

i dunno if i would have reintubated and asked for a chest tube. i wasn't there, though. from what you describe, I would have given a slug of propofol to regain control, mask and get some vitals on a still/sedated patient, mebbe CXR, proceed from there. maybe sats are fine with a mask, let him wake up again after rebooting with the propofol button.

sounds like the whole thing was a goat rodeo.

 

[Ignatius J]

Got to love academia....the patient may have an increased chance of dying but by God we got someone else in the study....yes, this 4th year resident is ready to get out.