pneumothorax and PPV

[B-Bone]

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case from call last night. unhelmeted motorcycle passenger thrown from bike. nasty depressed skull fx, SDH, lots pf edema/midline shift, pupils mid-position and minimally reactive. also has small traumatic right pneumothorax, shown on CT. trauma surgery places a right SC triple lumen after the CT and patient comes emergently to OR with like 5 minutes heads up. I get the case started, but hand off to my partner pretty much right away as I've been up all night and it's time to go home.

Anyway, my question is would folks normally have a chest tube placed in a patient with a (small) pneumothorax who you are paralyzing and planning to positive-pressure ventilate , likely for a prolonged period? I brought this up to the trauma guy who took the patient in the ED, and he was like "huh. I guess I could've placed a chest tube". at this point we're prepped and draped and operating, so i've marked the 2nd intercostal space and listen to breath sounds every time the pressure starts to drift, but I feel like trauma kind of dropped the ball on this one. am I being too conservative? Any thoughts?

 

[Bostonredsox]

case from call last night. unhelmeted motorcycle passenger thrown from bike. nasty depressed skull fx, SDH, lots pf edema/midline shift, pupils mid-position and minimally reactive. also has small traumatic right pneumothorax, shown on CT. trauma surgery places a right SC triple lumen after the CT and patient comes emergently to OR with like 5 minutes heads up. I get the case started, but hand off to my partner pretty much right away as I've been up all night and it's time to go home.

Anyway, my question is would folks normally have a chest tube placed in a patient with a (small) pneumothorax who you are paralyzing and planning to positive-pressure ventilate , likely for a prolonged period? I brought this up to the trauma guy who took the patient in the ED, and he was like "huh. I guess I could've placed a chest tube". at this point we're prepped and draped and operating, so i've marked the 2nd intercostal space and listen to breath sounds every time the pressure starts to drift, but I feel like trauma kind of dropped the ball on this one. am I being too conservative? Any thoughts?

You have enough to deal with with the acute bleed. I will put in the chest tube when he get to the ICU. If he starts to develop problems ventilating intraop or has cardiac output changes from an expanding PTX on ppv during the case, a ctube should be put in intraop. But a small traumatic PTX in the setting of a big brain bleed can be fixed later in ICU. I have done this before in therapeutic hypothermia pts that had iatrogenic ptxs from mechanical CPR in the field. They came in, got resussitated in ED. Went to cath lab. Got stented. Came up to MICU post cath and I put in the Chest tubes then.

IMO unless they are causing hemodynamic problems, they are not urgent and can be done on arrival to ICU. Unless that transition is expected to be 4-5 hours or something crazy long. In that case I'd come to the OR or cath lab and throw in the tube while you guys are dealing with the primary problem.

 

[dotcb]

In the patient with known PTX who needs intubation you can do a few things with similar results.

Needle decompression, intubate, chest tube.

Intubate, see what happens, ready to needle decompress or quickly place chest tube

Chest tube and intubate at the same time.

I don't think they're really all that different as long as you know what you're dealing with and are ready to handle it.

 

[periopdoc]

I would request a chest tube prior to prep and drape. Emergent chest tubes in the middle of the case usually aren't fun.

- pod

 

[B-Bone]

I would request a chest tube prior to prep and drape. Emergent chest tubes in the middle of the case usually aren't fun.

- pod

this is how I felt. I talked to the available trauma surgeon about it, but he and my partner who took over went the "wait and see" route. I think the plan of "hopefully we can find/get to the right spot under the drapes when the patient gets hemodynamically unstable from a tension pneumo (which also inhibits venous return and shoots up ICP)" should not be plan A. But, to each his own, I guess.