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I have never done one like that...
It seems that CXR will always come first....
It seems that CXR will always come first....
Have anyone of you put a chest tube in pneumothorax without get an CXR first?
- Thread starter seasurfer
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Absolutely I have.
If the patient has a tension PTX, sometimes you don't have time for the CXR. People may argue that you can do needle decompression, but honestly that treatment has been less effective in my experience, and is obviously less definitive.
You'll run into this situation in the trauma bay relatively often. If the patient has a mechanism for it, and presents with hypotension, respiratory distress, and decreased or absent breath sounds, I'm putting the chest tube in immediately....or more likely having the intern do it.
Still, all of that stress aside, I also think it's important to be careful. Given the amount of HIV and hep C in a trauma population, I don't want an over-zealous intern cutting their finger on a broken rib.
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Tension PTX is a clinical dx. If you get a CXR, you are already behind the 8 ball.
Most invasive procedure outside of the OR (i.e. floor, ER, ICU)
- Cranial Burr Holes
- Thoracotomy
- post-cardiac surgery sternotomy
- foley insertion (by far the most invasive.... just ask my male patients!)
Most invasive procedure outside of the OR (i.e. floor, ER, ICU)
- Cranial Burr Holes
- Thoracotomy
- post-cardiac surgery sternotomy
- foley insertion (by far the most invasive.... just ask my male patients!)
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Probably opening the chest in the SICU as a PGY-2 for a post-CABG who popped off a graft. I still think I am walking a little funny after that experience.
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CXR only comes first when the techs are trying to horn their way in to get the cspine, chest and pelvis films done like its some phoned in order without attention to mechanism.
As others have noted, you have mechanisms and signs and symptoms - tube first and questions.
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Must agree with the caveat... I do not concern myself with breath sounds present, absent, or quality of... I can rarely hear very much in a noisy trauma room. If they got the mechanism and additional clinical signs I tube them.
Agree.... unless the tube is "elective" because you find pathology incidentally/after a procedure....
A fundamental principle of surgery is if you clinically suspect need for Chest Tube then put chest tube. You do not wait for CXR to guide emergent chest tube. Also, when all else fails during emergent code, or even if all else has not failed..... you place a chest tube. The vast majority of chest tubes I have placed have been without imaging.
You will rarely be able to confirm the need for chest tube after it was placed... as you have now treated the pneumothx if it was there...
My only indication for needle decompression is the absence of a knife and tube.... I can evacuate and/or decompress the chest far quicker with a knife then a needle. That is obviously not the same situation a paramedic would find themselves in....
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deleted89854
I would be severely beaten if I ran a CXR by one of the trauma attendings with a giant pneumothorax on it. Needle decompression is usually done by EMTs or medicine folks. Why bother when you can put in a chest tube in 1-2 minutes?
On a side note, the "air rush"/fart noise you get when you're correct is very satisfying.
On a side note, the "air rush"/fart noise you get when you're correct is very satisfying.
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That's a slow Monday morning tube.....
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I've actually seen a CT of a tension pneumo....
In their defense, the staff trauma surgeon didn't even pick up on it, because the patient wasn't really having trouble breathing, I guess (I wasn't there - it was presented in trauma conference). He did get short of breath when they put in the chest tube though. He recovered without a problem.
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Probably opening the chest in the SICU as a PGY-2 for a post-CABG who popped off a graft. I still think I am walking a little funny after that experience.
Sorry, just had to comment on the "walking funny" thing-In India, whenever someone comments about a girl "walking funny", it's (kinda) derogatory as it implies that she has been "doing the nasty".
Otherwise I agree with the general consensus-for a tension pneumothorax, tube first-you should never see an x-ray of it!
PS: I thought I already posted this, but doesn't seem to show up, so trying again. Sorry if I doublepost.
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It can be used that way here in the US although I was using the phrase in reference to certain sphincter tone. Only women who don't stretch before other activities are prone to walking funny, IMHO. Fortunately I am very limber. 😉
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Probably opening the chest in the SICU as a PGY-2 for a post-CABG who popped off a graft. I still think I am walking a little funny after that experience.
How about doing a C-section on a heroin overdose patient being coded in the ER at a hospital with no obstetrics?
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if the patient wasnt having trouble breathing, then it wasnt a tension pneumothorax.
You can have a big pneumo with significant mediastinal shift and no symptoms- that isnt a tension ptx.
but if you want to be a purist- tension pneumothorax is accompanied by hypotension and/or hypoxia.
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I didn't see the patient. I imagine he was having some trouble breathing (it was penetrating trauma) but not enough that anyone thought it was a tension. It wasn't my diagnosis either - the attending was the one who called it that.
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Lots of times, most often in the Trauma Bay when patients come in with decreased breath sounds and a positive pleural FAST. Or when they've already had needle decompression in the field.
Or when a patient has decreased breath sounds on the vent, in the middle of a PEA arrest.
Or when a patient has decreased breath sounds on the vent, in the middle of a PEA arrest.
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I would go so far as to say that tension pneumothorax is DEFINED by hemodynamic compromise. You cannot diagnose it radiographically.
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clarification.... should NEVER diagnose it by CXR or CT or etc....
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Probably opening the chest in the SICU as a PGY-2 for a post-CABG who popped off a graft. I still think I am walking a little funny after that experience.
What did you do once you cut the wires and got the sternum open?
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I can't speak to WS particular experience... but the situation is usually more about the tamponade created by the spraying graft. You open the sternum and decompress and then get back to OR. You hope there is not too much infarction from the perfusion loss to the target distribution. But, the emergency mandated opening is not the infarction it is the tamponade.
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Ah, of course, thanks for the clarification. For some reason I didn't put two and two together on that one...was stuck thinking how the hell someone would go about a bedside re-do CABG. And I did a month of CT surgery too, I should know. 😛
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deleted89854
Just curious - once you've got the tamponade released how do you recommend getting some kind of hemostasis while you're being wheeled back to the OR? Seems like direct pressure would be kind of difficult to apply. . .
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It depends on the specifics... i.e. where is the leak. If it's on the aorta you can put a finger or even a side biting clamp on it. If it's at the distal where the graft tore free.... just pinch off the vein. The coronary target will likely ooze... but remember it was grafted distal to a significant stenosis....
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vancozosyn said:
Yep, yelled at nurse to page attending, cut wires, released tamponade, yelled at nurse to call OR and tell them we're coming, pinched off vein and rode on SICU bed to OR holding the distal graft between my fingers. Fortunately, he didn't infarct too much muscle.
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so how did you know that the graft had popped off? I'd hate to be the resident that re-opened someone's chest when that wasn't what needed to be done!
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I didn't know that the graft had popped off - at least not initially. I knew he seemed to be in tamponade, paged the CT fellow, told him my worry, he said the graft might have popped off or the guy had a rupture and told me to get started opening the chest and he'd be there ASAP (he was probably in the call room having sex with the PA when I called 😉 ). I had the chest open when he walked in.
And yes, had I/we been wrong, it might have been a tad more difficult to explain at M&M. Sometimes you just gotta do something when a patient is dying in front of you.
Funny thing is, talking about it now, it seems like it happened to someone else.
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