Chest tube

[allendo]

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Has anyone had a chest tube track sub q and look ok on xray? I've put in many tubes and had my first bad exp last night, eventually caught the mistake and fixed it but it scared the hell out of me and now feel like an idiot.

 

[Birdstrike]

Has anyone had a chest tube track sub q and look ok on xray? I've put in many tubes and had my first bad exp last night, eventually caught the mistake and fixed it but it scared the hell out of me and now feel like an idiot.

No. I've never had one go subcutaneous. I dont do that many though. Once the tube slides in the chest there's very little resistance. I can't imagine how much resistance there would be if you advanced it far enough subQ that it "looked ok" on cxr. If it's not emergently needed, I let the surgeon come in and do it. If it's emergent and the patient is unstable, I do them because I have no choice. Most chest tubes can wait a little bit. Also, you have to make a big enough cut in the skin and hole in the chest that you can verify tube placement with your finger.

 

[Hawkeye Kid]

Has anyone had a chest tube track sub q and look ok on xray? I've put in many tubes and had my first bad exp last night, eventually caught the mistake and fixed it but it scared the hell out of me and now feel like an idiot.

Yes, and on the AP CXR it looked as though placement was ideal. In fact, I had this happen with the first chest tube I ever did as an intern. With subcutaneous air, the facial planes separate and it's very easy to slide the tube through the tissue without much resistance. My practice now is to verify tube placement with a finger (follow the tube to the chest wall and make sure that it goes between the ribs) prior to suturing the tube in place.

 

[med2UCC]

Yes, and on the AP CXR it looked as though placement was ideal. In fact, I had this happen with the first chest tube I ever did as an intern. With subcutaneous air, the facial planes separate and it's very easy to slide the tube through the tissue without much resistance. My practice now is to verify tube placement with a finger (follow the tube to the chest wall and make sure that it goes between the ribs) prior to suturing the tube in place.

Haven't done it but have done many other things that made me feel like an idiot. Get used to it - we all feel like idiots periodically, and then we learn from the experience. This was the sage advice I got from a colleague who is 70 and still practicing. Cheers,
M

 

[docB]

It hasn't happened to me but it's a well known pitfall. It's yet another thing that shows how difficult it is to take care of morbidly obese people.

 

[keeping-it-real]

+1 here... it happens. My patient was morbidly obese and I had 200cc of blood on placement and thought I was in. The tube easily tracked into the sub-q space; the surgery resident caught my mistake and readjusted it appropriatedly. Biggest thing I learned was that you need to make a larger incision in these obese patients and get adequate exposure to the underlying chest wall which may be 6 or more inches beneath the skin. And make certain you hear the rush of air upon pleural entrance.

And yes, it's embarrassing.

 

[allendo]

My incision was smaller on this tube than the ones in the past, will not try that again.

 

[AmoryBlaine]

Do not count on resistance to passage to determine if you are subq, even in obese but not massive patients the tube can just slide right along the chest wall.

To me if you don't definitively feel the tube going between two ribs I would keep working until you do even if that means you have to make a bigger skin incision.

When you think about it, the skin incision is just a laceration and a clean one at that. It may not look great but it will heal ok. Having a surgeon say it looks sloppy is a damn sight better than having them discover your tube is subq.

 

[pinipig523]

When I was on trauma rotation, me and my then senior had one that tracked extrapleurally for a little bit. We could not figure it out, we thought we were facing a ton of extrapulmonary adhesions.

Trauma attending came by and popped right through the pleura. And we felt stupid.

 

[allendo]

When I was on trauma rotation, me and my then senior had one that tracked extrapleurally for a little bit. We could not figure it out, we thought we were facing a ton of extrapulmonary adhesions.

Trauma attending came by and popped right through the pleura. And we felt stupid.

I had the hole through the pleura, but when I pulled my finger out to insert the tube I did it with one hand and slipped it sub q

 

[Lumberg]

It's so funny to see this thread today because I had my first chest tube complication last nite...at least since I was an intern and used to put them anywhere but inside the chest.

80 yo F spontaneous PTX. Stable but I love chest tubes and I always do them in the ED when I get the chance. I usually make a tiny incision, track my index finger into the pleural space and guide the tube cephald into the apex. Have had no complications since a surgery resident showed me this technique during a trauma code in my 2nd year. Anyway uneventful procedure, good woosh, easy placement, hook up the pleurovac and...nothing. Sats actually start dropping and I'm getting kinda antsy. (One reason is that I'm already getting slammed w/ patients - this was my first pt of the day. As I'm getting everything set up I realize that my tech/nurse had brought me a thoracotomy tray instead of a chest tube tray. I'm looking down, see rib spreaders and thinking...WTF!? So no tube, petroleum guaze, etc, etc. 20 min delay while someone finds me the right kit). So she starts to wake up and is still pretty dyspneic. I reposition the tube 3-4 times, no success. STAT portable chest and the tube is kinked about 180 degrees, essentially folded back onto itself. PTX completely resolved, though. Weird. There was no resistance, no difficulty advancing tube whatosever. Finally just yanked it and placed a 2nd one in the same site w/o any trouble but I've never even heard of that happening before. Kinking yes, but I've never seen a tube bend like that. Of course this whole process took about 90+ minutes in my single cover ED and I got hammered for the rest of my shift. Good times.

I agree w/ advice above. I keep my finger in the hole and guide the tube through w/ my off hand to ensure proper placement. I also direct the tube posteriorly (perpindicular to the floor) and cephalad and it almost always get right up into the apex.
Cheers.

 

[Dwindlin]

No,it gets access air out of the chest when you are injured.
Your lungs collapse and that is the only way to get them back in to their original shape.
Seen it many a times on ER.
A Dutch hospital series:with real people.
Space

Mind blown.

 

[Arcan57]

If it's just a PTX, why not use a pneumodart and save yourself time and the patient some increased pain?

 

[crewmaster1]

It's so funny to see this thread today because I had my first chest tube complication last nite...at least since I was an intern and used to put them anywhere but inside the chest.

80 yo F spontaneous PTX. Stable but I love chest tubes and I always do them in the ED when I get the chance. I usually make a tiny incision, track my index finger into the pleural space and guide the tube cephald into the apex. Have had no complications since a surgery resident showed me this technique during a trauma code in my 2nd year. Anyway uneventful procedure, good woosh, easy placement, hook up the pleurovac and...nothing. Sats actually start dropping and I'm getting kinda antsy. (One reason is that I'm already getting slammed w/ patients - this was my first pt of the day. As I'm getting everything set up I realize that my tech/nurse had brought me a thoracotomy tray instead of a chest tube tray. I'm looking down, see rib spreaders and thinking...WTF!? So no tube, petroleum guaze, etc, etc. 20 min delay while someone finds me the right kit). So she starts to wake up and is still pretty dyspneic. I reposition the tube 3-4 times, no success. STAT portable chest and the tube is kinked about 180 degrees, essentially folded back onto itself. PTX completely resolved, though. Weird. There was no resistance, no difficulty advancing tube whatosever. Finally just yanked it and placed a 2nd one in the same site w/o any trouble but I've never even heard of that happening before. Kinking yes, but I've never seen a tube bend like that. Of course this whole process took about 90+ minutes in my single cover ED and I got hammered for the rest of my shift. Good times.

I agree w/ advice above. I keep my finger in the hole and guide the tube through w/ my off hand to ensure proper placement. I also direct the tube posteriorly (perpindicular to the floor) and cephalad and it almost always get right up into the apex.
Cheers.

I always make sure the tube can be rotated in my fingers before I suture it in place, this will confirm it isn't kinked as a kinked tube will not spin around/rotate. Subq tubes also shouldn't have humidity in the tube with respirations and you should be able to feel it enter the rib cage. With regards to extrapleural tubes, this usually happend when you enter the chest cavity in timid fashion (with the curved kelly clamps) and don't puncture the pleura, but gradually push it away from the chest wall (into the chest cavity). Then you tube ends up in the thoracic cavity but not through the parietal pleura.

 

[Tiger26]

I always make sure the tube can be rotated in my fingers before I suture it in place, this will confirm it isn't kinked as a kinked tube will not spin around/rotate. Subq tubes also shouldn't have humidity in the tube with respirations and you should be able to feel it enter the rib cage. With regards to extrapleural tubes, this usually happend when you enter the chest cavity in timid fashion (with the curved kelly clamps) and don't puncture the pleura, but gradually push it away from the chest wall (into the chest cavity). Then you tube ends up in the thoracic cavity but not through the parietal pleura.

great tip

 

[DrQuinn]

Being out in the community now i think i've only done one true chest tube, can't recall what it was for...
but now we do that cool Seldinger technique, can't recall if its Thal-Quik or Quik-Thal. Pretty slick, and really freakin' easy to do. Youtube it. ANd it pays the same as the old school thoracostomy.
Good tip on the twisting it, I learned that the hard way in residency, kinked it, and the surgery resident told me about that trick.

I think my first chest tube I put through a liver abscess... thought it was empyema but atleast we diagnosed the liver abscess...

Q

 

[Groove]

I put one in a 3yo other night with a large tension PTX and managed (somehow) to place it between the first and second rib. It worked, and was in the apex, but for the life of me I have no idea how I tracked up that high. Cut at nipple, or at least I thought, anterior axillary line, tracked up one rib, kids arms were held straight up against his head. The only thing I can think of is that either the nurse vigorously holding his arms up and pulling might have pulled the skin up to where I made the incision too high, or that I thought I was tracking up one rib, used to the space distance on adults and just mis-judged. Luckily, I'm pretty meticulous about entry into the pleural space, bracing the kelly, etc.. so I didn't lacerate or shove anything into his subclavian. After I saw the CT Chest, my sphincter tightened a bit seeing it so high, but everything turned out o.k.

Anybody ever done anything like that? First time I've ever placed one that high, but then again... first time I've placed one in a 3yo...

And I still don't get the whole twist/rotate the chest tube thing... I mean, I see surgery do it, but it seems to me that it would increase your risk of kinking the tube against something. Also, something I learned about seeing some of those 180 degree kinks, is to finger inside the chest wall as far as you can and feel around for adhesions. I had a spontaneous PTX on a bad emphysema guy with bullae and pleural blebs all over his chest xray, felt inside and adhesions all over the place, tried to break them up but tube still kinked but I also always worry about the tube being forced into lung parynchema with those guys, forced into the lung by the adhesions so I go nice and slow and feel for any resistance...

 

[Groove]

I keep my finger in the hole and guide the tube through w/ my off hand to ensure proper placement. I also direct the tube posteriorly (perpindicular to the floor) and cephalad and it almost always get right up into the apex.
Cheers.

Lumberg, are you saying you keep your finger in the hole and then pass the tube over the top of your finger? Are you clamping onto the tip with the Kelly and then shoving it over the top? Maybe my fingers are too big or the hole isn't big enough, but I can't seem to make enough room to do that. Perhaps I need to spread the intercostals with the kelly better...

 

[Rendar5]

And I still don't get the whole twist/rotate the chest tube thing... I mean, I see surgery do it, but it seems to me that it would increase your risk of kinking the tube against something.

I think that twisting it after it's inserted is a quick test of whether it's kinked or has a straightpath. Not something to do necessarily during insertion, but after. Haven't done it myself but I can see myself doing that quickly right before suturing it in.

 

[Tay2]

kids arms were held straight up against his head.

Just curious, why was the kid's arms held straight up against his head?

Was he moving around a lot? What about his legs?

 

[BoardingDoc]

Just curious, why was the kid's arms held straight up against his head?

Was he moving around a lot? What about his legs?

I'll be curious to see what sort of response you get and how good Groove's memory is, seeing as this happened, you know, 13 years ago.

 

[Jabbed]

For morbidly obese patients I normally put the Kelly clamps with the chest tube directly into the chest and then direct it superiorly. It’s much easier to direct a 6 inch long clamp through a whole bunch of fat than it is to direct my fingers.

Picked this up during covid when we were putting in chest tubes in 500+ lbs patients with whole body subq emphysema.

Sometimes I also find it helpful to measure how much tissue there is before getting into the chest wall on CT so I can gauge how much of the tube is outside of the chest when I secure it.

SC tubes, fissure tubes, and tubes that are barely in the chest are all embarrassing but they happen so might as well learn from them.

As long as you don’t put it intracardiac, intrapulmonary, or subdiaphragmatic, everything is forgivable and correctable.

 

[TooMuchResearch]

I'll be curious to see what sort of response you get and how good Groove's memory is, seeing as this happened, you know, 13 years ago.

I scrolled up just a couple of posts and saw DrQuinn and realized I may have stepped into a time capsule.

 

[southerndoc]

I scrolled up just a couple of posts and saw DrQuinn and realized I may have stepped into a time capsule.

Haven't heard that name in a long time!