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Can I just do a pig tail for everything?
Can I just do a pig tail for everything?
There's research to support small bore/pigtail catheters for hemothorax as well. We do not place large bore catheters in all of our hemothoraces. In the resuscitation bay in a crash situation, yes. After CT in patients that are stable or semi-stable, they usually get a pigtail catheter.Yes for spontaneous pnuemothorax. No for significant traumatic hemothorax.
Maybe not the question you were asking, but can't for everything unfortunately.
Yes for spontaneous pnuemothorax. No for significant traumatic hemothorax.
Maybe not the question you were asking, but can't for everything unfortunately.
See bolded.There's research to support small bore/pigtail catheters for hemothorax as well. We do not place large bore catheters in all of our hemothoraces. In the resuscitation bay in a crash situation, yes. After CT in patients that are stable or semi-stable, they usually get a pigtail catheter.
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Traumatic Hemothorax: Pigtail vs Chest Tube - REBEL EM - Emergency Medicine Blog
Is a 14 Fr pigtail catheter noninferior to a 28–32 Fr chest tube for managing traumatic hemothorax in hemodynamically stable patients?rebelem.com
Can I just do a pig tail for everything?
So much more fun.Can I just place a large bore chest tube for everything?
Yep
It's what I've been doing for years now
We still use them for large volume hemothoraces (level I trauma center).See bolded.
I appreciate trying to use data to inform CT usage, but this study was underpowered with selection bias. Hard to draw any conclusions and yet they tried to do so.
I don’t think you are going to get out of placing a thoracostomy tube with a moderate to large volume hemothorax, especially if hemodynamic instability (I know study excluded, but also subjectively).
I never really understood the big chest tube is better argument. If a kid needs a chest tube for a hemothorax, they're getting something that would be considered small for an adult yet the blood drains adequately fast enough.
If I'm conscious and in the situation of needing a chest tube, you're getting a big F-You and legit threat of litigation if you propose putting in a large bore chest tube for just about any reason.
Thank you all for your feedback. Based on the fact I only ever want to reinforce my own starting opinion, I will now only do pig-tail catheters and ignore all the other opinions about this.
On a serious note, I’ve seen plenty of comments here saying we now rarely need to intervene with PTX. Can someone update me here? Last I learned, all but small PTX needs a chest tube or pig tail.
Can I just do a pig tail for everything?
Can I just place a large bore chest tube for everything?
Thank you all for your feedback. Based on the fact I only ever want to reinforce my own starting opinion, I will now only do pig-tail catheters and ignore all the other opinions about this.
On a serious note, I’ve seen plenty of comments here saying we now rarely need to intervene with PTX. Can someone update me here? Last I learned, all but small PTX needs a chest tube or pig tail.
Are you talking about the hospitalist saying you have to consult surgery or put a chest tube in? In my experience, they'd admit and consult pulm who will just watch it and continue to treat the COPD exacerbation. Not every community hospital will have pulm but I'd bet a majority do unless you are incredibly rural.It's just so hard to implement new research.
For all you community ER docs, just imaging this.
you get a guy with COPD coming in with SOB. They are not NIPPV SICK.
You get the obligatory chest xray that you expect to be negative.
"mild apical pneumo. No consolidation."
You cringe becasue you know nothing needs to be done. So you try to admit the patient for albuterol and steroids.
EVERY SINGLE community doc will say "you have to consult surgery or put a chest tube in."
They won't rely on your expertise. Or your judgement. They will all say "What happens if pneumo BLOW UP and the pt arrests! I don't put in chest tubes."
EVERY SINGLE ONE. Most community docs are just ****ies.
Yeah so this is the issue. I can only admit a patient with a chest tube at the big place. At all the small places, it seems the only people still able to take care of chest tubes are... emergency physicians. Even at one of the small places, they asked me to pull a chest tube "because the surgeon isn't coming in today and he says it's ready to come out." This was years ago...I know better now than to be a "team player" just because someone doesn't want to do their job.It's just so hard to implement new research.
For all you community ER docs, just imaging this.
you get a guy with COPD coming in with SOB. They are not NIPPV SICK.
You get the obligatory chest xray that you expect to be negative.
"mild apical pneumo. No consolidation."
You cringe becasue you know nothing needs to be done. So you try to admit the patient for albuterol and steroids.
EVERY SINGLE community doc will say "you have to consult surgery or put a chest tube in."
They won't rely on your expertise. Or your judgement. They will all say "What happens if pneumo BLOW UP and the pt arrests! I don't put in chest tubes."
EVERY SINGLE ONE. Most community docs are just ****ies.
IDK man, I think your shops aren't generalizable. I admit patients with very small pneumos to medicine with a plan to do nothing except give O2 and repeat a CXR later. We don't have thoracics or anyone in house besides the ED for that matter that does chest tubes. Medicine generally trusts us that these are nothing to worry about.EVERY SINGLE community doc will say "you have to consult surgery or put a chest tube in."
They won't rely on your expertise. Or your judgement. They will all say "What happens if pneumo BLOW UP and the pt arrests! I don't put in chest tubes."
EVERY SINGLE ONE. Most community docs are just ****ies.
Can’t put in a pigtail if there’s not a good landing zone which is a limitation
I assume he's talking about those rather robust patients with biscuit poisoning. Tough to put a needle through 8 inches of fat. I could be completely wrong though. Wouldn't be the first time today."landing zone" ?
Sorry, I mean the safe pocket of air or fluid needed to get your needle into without hitting lung."landing zone" ?
If there isn't an area of fluid or air big enough to safely get into with a pigtail, why are you even considering a chest tube of any kind?Sorry, I mean the safe pocket of air or fluid needed to get your needle into without hitting lung.
Biscuit poisoning? LOLI assume he's talking about those rather robust patients with biscuit poisoning. Tough to put a needle through 8 inches of fat. I could be completely wrong though. Wouldn't be the first time today.
I posted this in the past. When I worked in SC, had a pt I had to tap, that was, what's the word? Corpulent? Had rads do it. Rads called me back, saying they used "the harpoon", and had to hub the needle to get the fluid.Biscuit poisoning? LOL
Our kids have a longer needle for the obese. I swear it looks so long that you could do a pericardiocentesis with it.
How do we make sure of this?Sorry, I mean the safe pocket of air or fluid needed to get your needle into without hitting lung.
PTX draining into the subcutaneous space, loculated PTX or HTX sometimes.If there isn't an area of fluid or air big enough to safely get into with a pigtail, why are you even considering a chest tube of any kind?
For pigtails, I just trochar it in. No issues... people have been harpooning whales for centuries.I assume he's talking about those rather robust patients with biscuit poisoning. Tough to put a needle through 8 inches of fat. I could be completely wrong though. Wouldn't be the first time today.
Ultrasound guidance... and if you take a picture you get more RVUs.How do we make sure of this?
I thought we just go fifth intercostal, no?
I posted this in the past. When I worked in SC, had a pt I had to tap, that was, what's the word? Corpulent? Had rads do it. Rads called me back, saying they used "the harpoon", and had to hub the needle to get the fluid.
This is the future of America.
I was doing a left sided pigtail a year or so ago. Big fat guy. I'm nearly hubbing the finder needle before I can grab a wire when the needle suddenly starts filling rather rapidly with fairly bright appearing blood.For pigtails, I just trochar it in. No issues... people have been harpooning whales for centuries.
These make me nervous. I wouldn't put one in unless that lung is way down since I'm worried I'm going to go through the parenchyma or something else important. I can't comprehend why more kits aren't the Seldinger kind where you at least have the feedback of aspirating air or blood before feeding the much less scary wire.For pigtails, I just trochar it in. No issues... people have been harpooning whales for centuries.
I remember someone here posted that chest tube trocars are associated with markedly worse outcomes.
99% of the time I'm placing a pig tail, the lung is pretty far down and the second I feel any release I'm pulling the cutting needle out of the trochar and connecting the syringe to the trochar.These make me nervous. I wouldn't put one in unless that lung is way down since I'm worried I'm going to go through the parenchyma or something else important. I can't comprehend why more kits aren't the Seldinger kind where you at least have the feedback of aspirating air or blood before feeding the much less scary wire.
IDK man, I think your shops aren't generalizable. I admit patients with very small pneumos to medicine with a plan to do nothing except give O2 and repeat a CXR later. We don't have thoracics or anyone in house besides the ED for that matter that does chest tubes. Medicine generally trusts us that these are nothing to worry about.
FWIW, I use a large bore needle with lidocaine and alternate injecting and aspirating until I get a few bubbles, then stop, remove my syringe, and feed my guide wire. Pretty straightforward after that.
I mean, both go into the chest, but they're rather different.part time hospitalist here
this has been my experience since residency over a decade ago. even moderate ptx some of the cavalier pulm guys will keep on o2 for a few days and reeval
i've only placed a couple chest tubes in residency. is there a large technical difference between inserting a pigtail vs a chest tube?