Question re: chest tubes

[goodoldalky]

Patient comes in, large HTX, shattered all of his ribs, and his HIV and HCV positive.

During exploration, how do you avoid stabbing your finger on a broken piece of rib in this case? Go slow? Double glove? Anything more scientific than that?

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[RustedFox]

Patient comes in, large HTX, shattered all of his ribs, and his HIV and HCV positive.

During exploration, how do you avoid stabbing your finger on a broken piece of rib in this case? Go slow? Double glove? Anything more scientific than that?

I have actually thought about this.

Although the situation hasn't happened to me in real-life (all the chest tubes I needed to place had some great anatomy) - there's no edict that says that you have to poke your finger in and "sweep the pleura". Another large kelly clamp could in theory do the same job and sweep away any pleural adhesions (never seen/felt one of those, either), and you could pass the clamp holding the chest tube over the kelly clamp that is in the incision that you created.

Disclaimer: Like I said, this is purely theoretical. Never done it.

 

[EM_Rebuilder]

I've never been stuck by a needle (yet..knock on wood) but I did go through the motions of the test once over a trauma code that I dropped a chest tube in..

Ever felt lungs with your bare finger? I was doing the whole sweep thing and was like 'hmm.. that lung feels a bit different'... it was when I pulled my finger back out that I realized half my glove finger was missing....

They didnt make it otherwise somebody would have had to go fishing for latex...


I have NO CLUE why it happened.. dont know if the glove was ripped before I went in, etc... but I often wondered if it was a busted rib that ripped it....

 

[Dane07MD]

Sticky situation. I like Fox's answer. I got a needlestick this year, from an otherwise fairly healthy woman. That sucked, but I can;t imagine knowing if the patient already has HIV/HCV

 

[RustedFox]

Sticky situation. I like Fox's answer. I got a needlestick this year, from an otherwise fairly healthy woman. That sucked, but I can;t imagine knowing if the patient already has HIV/HCV

I've poked myself before. Never a 'questionable' case, and never with a hollow-bore needle, but still - had to get baseline seroconversion yadda yadda on me and source. Made me think.

The academic discussion here is: why even sweep the pleura with your finger ? Who cares ? Put the damn tube in.

 

[goodoldalky]

I've poked myself before. Never a 'questionable' case, and never with a hollow-bore needle, but still - had to get baseline seroconversion yadda yadda on me and source. Made me think.

The academic discussion here is: why even sweep the pleura with your finger ? Who cares ? Put the damn tube in.

The other thing is that in blunt chest injury with a HTX you may not be able to see on a plain film if there is an elevated hemidiaphragm or diaphragmatic disruption with something in the way that you don't want to put a tube or kelly etc. through.

 

[member11223344]

this has come up in my ED when it comes to trying to drain an abscess in the arm. a resident pressed down to express the remaining pus and the remainder of a hypodermic needle (that started the abscess to begin with--pt said it was a pimple she'd popped) poked him in the finger. he ended up being fine but it was a great reminder that using your fingers, even if gloved, carries risk.

 

[RustedFox]

The other thing is that in blunt chest injury with a HTX you may not be able to see on a plain film if there is an elevated hemidiaphragm or diaphragmatic disruption with something in the way that you don't want to put a tube or kelly etc. through.

Good point... but that's why you're (we're?) taught to aim high with the chest tube; to minimize the chance of anything like that happening. Hit the nipple line and aim for their ipsilateral tonsil.

 

[Dane07MD]

I've poked myself before. Never a 'questionable' case, and never with a hollow-bore needle, but still - had to get baseline seroconversion yadda yadda on me and source. Made me think.

The academic discussion here is: why even sweep the pleura with your finger ? Who cares ? Put the damn tube in.

Yeah mine was not bad. Doing LP, had a trace amount of CSF on my gloved finger, and when I went to discard the 3cc glass lidocaine vile, a jagged edge punctured the glove and jammed some CSF right into my skin. Nonetheless, extra tests and a whole bunch of labs for me were the result...

Sadly, it was on an away rotation and the attending on was the program director. I was embarrassed. We'll see how that affects my match this Friday

(Champagne tap though. Pimped it.)

 

[FDNewbie]

Good point... but that's why you're (we're?) taught to aim high with the chest tube; to minimize the chance of anything like that happening. Hit the nipple line and aim for their ipsilateral tonsil.

Also consider changing the location of your chest tube site to someplace less traumatic. If it's for a hemothorax, you just want a large tube in, pointed downward. Doesn't have to be mid-axillary line. Not a hard & fast rule. You can put them more anterior or posterior. Higher or lower.

I've seen trauma surgeons do chest tubes through the pectoralis (horribly cruel; I don't suggest it). CT Surgery does chest (pericardial) drains (which are essentially chest tubes) just below the xyphoid. And I've seen a fair share of posterior chest tubes as well. Just a thought.

 

[BRIAN1986]

Agree with above

 

[RustedFox]

Question remains... why sweep w/ finger ?

 

[FDNewbie]

Question remains... why sweep w/ finger ?

I think sweeping the finger is important to:

A) Ensure you're IN the hemithorax, and not in the chest wall (yes, people have put chest tubes through the chest wall, vs. in the pleural space

B) Ensure the structure you're feeling is actually the lung (you can miss a diaphragmatic injury, and if that lung isn't moving, it may not be lung you're chest tube's heading toward (I've seen chest tubes placed into the stomach due to an unknown hiatal hernia)

C) Now that you know it's lung, you want to make sure the lung is NOT adhered to the thoracic wall. You want to put the chest tube into the pleural space, and not into the lung ITSELF lol. Bad. Bad.

 

[alphaholic06]

this has come up in my ED when it comes to trying to drain an abscess in the arm. a resident pressed down to express the remaining pus and the remainder of a hypodermic needle (that started the abscess to begin with--pt said it was a pimple she'd popped) poked him in the finger. he ended up being fine but it was a great reminder that using your fingers, even if gloved, carries risk.

Wow! That sucks. That makes me less likely to apply a lot of pressure to an abscess.

 

[RustedFox]

Disclaimer: I'm not arguing with you. I'm trying to brainstorm ways for us to save our fingers from danger.

I think sweeping the finger is important to:

A) Ensure you're IN the hemithorax, and not in the chest wall (yes, people have put chest tubes through the chest wall, vs. in the pleural space

B) Ensure the structure you're feeling is actually the lung (you can miss a diaphragmatic injury, and if that lung isn't moving, it may not be lung you're chest tube's heading toward (I've seen chest tubes placed into the stomach due to an unknown hiatal hernia)

C) Now that you know it's lung, you want to make sure the lung is NOT adhered to the thoracic wall. You want to put the chest tube into the pleural space, and not into the lung ITSELF lol. Bad. Bad.

A) A big enough incision should be able to suffice. If you can't get a good return of something, then you're not in the pleural cavity. Stick the large kellys in there, OPEN them, and take a good, square look.

B) In theory, a chest tube placed 'high enough' shouldn't hit anything but lung.

C) Closed kellys *should* be able to sweep away lung adhered to the pleura, as well.

Again. I don't want to sound confrontational - I want someone to debunk my thoughts, if there's a GOOD reason why a kelly clamp just won't do.

 

[FDNewbie]

Disclaimer: I'm not arguing with you. I'm trying to brainstorm ways for us to save our fingers from danger.

No worries

A) A big enough incision should be able to suffice. If you can't get a good return of something, then you're not in the pleural cavity. Stick the large kellys in there, OPEN them, and take a good, square look.

Yes, but unless this is a trauma, where I'm slicing & dicing anyway, I prefer the smallest hole I need to get by with - which is finger-sized. Don't really see at all; just do by feel (which doesn't help your very valid concern).

B) In theory, a chest tube placed 'high enough' shouldn't hit anything but lung.

Yep. But it happens nonetheless.

C) Closed kellys *should* be able to sweep away lung adhered to the pleura, as well.

I'd be careful what you do and how much of it you do blindly. Kellys are blunt, but can still lacerate the lung. And especially on left chest tubes on small patients, you BARELY want that Kelly in there. Cuz you know what's *RIGHT NEXT* to the chest wall? The heart. And many a chest have been opened up emergently secondary to someone being not as careful as they needed to be when trying to puncture the pleura with the Kellys (if you don't limit how much it goes it, it'll do just that: GO IN. Far lol).

Again. I don't want to sound confrontational - I want someone to debunk my thoughts, if there's a GOOD reason why a kelly clamp just won't do.

Not at all man. Didn't take it that way

 

[soonereng]

Patient comes in, large HTX, shattered all of his ribs, and his HIV and HCV positive.

During exploration, how do you avoid stabbing your finger on a broken piece of rib in this case? Go slow? Double glove? Anything more scientific than that?

How about using the ortho surgical gloves. A lot stronger than even double gloving...

 

[RustedFox]

FDNewbie: Hey man, how's York these days? (I'm a Pennsylvania boy)

You bring up some good points. One thing I'd like to say is that when I'm puncturing the pleura with the kelly, I use TWO hands; my right hand is applying pressure with the kelly to puncture, and my left hand is on the chest wall also applying pressure with the kelly... this way, I "push" at two points, and can control the kelly better than I could by just pushing with one hand at the handle-end of the kelly. I've found that this results in a far more 'controlled entry'.

Lacerating the lung... yeah... Kellys are blunt, but can still do some damage. Can you think of another (softer?) object that we can slide in there in lieu of our finger to sweep away the lung ? I'm all for keeping my fingers out of there if I at all can.

 

[Daiphon]

Lacerating the lung... yeah... Kellys are blunt, but can still do some damage. Can you think of another (softer?) object that we can slide in there in lieu of our finger to sweep away the lung ? I'm all for keeping my fingers out of there if I at all can.

Try a peds uncuffed with a mini stylet. Soft, small, and stylet gives it some rigidity for sweeping without (but will usually give before you do damage). Right angle it & twirl.

Done this a few times in situations like the OP where the thought of PEP was very real.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

 

[RustedFox]

Gooood idea.

If there's any way to protect my fingers, I'm all for it.

 

[Daiphon]

Gooood idea.

If there's any way to protect my fingers, I'm all for it.

This just sprouted a new thread idea...

Sent from my DROID BIONIC using Tapatalk

 

[GoBuckeyes913]

Patient comes in, large HTX, shattered all of his ribs, and his HIV and HCV positive.

During exploration, how do you avoid stabbing your finger on a broken piece of rib in this case? Go slow? Double glove? Anything more scientific than that?

Go slow. Not like an hour long slow, but you can still get a tube in an unstable blunt chest trauma patient in like 2 minutes while still being cautious. I've shredded through double gloves (thank you Shock Trauma) and it's usually happened when I was too quick and sloppy. It stopped when I took a little more time and caution, or at least only got 1 layer.

I dunno, just my experience. Sometimes if the trauma is that bad, leave it to the CT/Trauma surgeon if it's available to you for other options mentioned which I've also seen done but would never feel comfortable doing myself.

 

[WilcoWorld]

this has come up in my ED when it comes to trying to drain an abscess in the arm. a resident pressed down to express the remaining pus and the remainder of a hypodermic needle (that started the abscess to begin with--pt said it was a pimple she'd popped) poked him in the finger. he ended up being fine but it was a great reminder that using your fingers, even if gloved, carries risk.

We could sue our patients over cases like this. Perhaps we should.

 

[gutonc]

We could sue our patients over cases like this. Perhaps we should.

Imagine the payout you're going to score from the junkie with half a broken needle in his shooting arm abscess.

But your point is interesting.

 

[FDNewbie]

FDNewbie: Hey man, how's York these days? (I'm a Pennsylvania boy)

Busy as heck. It's insane. But great for training ;-) I threw up my $0.02 of my experience @ York here: http://forums.studentdoctor.net/showthread.php?t=771538 if you want some more details.

You bring up some good points. One thing I'd like to say is that when I'm puncturing the pleura with the kelly, I use TWO hands; my right hand is applying pressure with the kelly to puncture, and my left hand is on the chest wall also applying pressure with the kelly... this way, I "push" at two points, and can control the kelly better than I could by just pushing with one hand at the handle-end of the kelly. I've found that this results in a far more 'controlled entry'.

Sounds good. I actually use my right hand to push (I'm right handed), and my left hand against the chest wall, almost applying counter pressure against my right hand. That way, I can limit how far in the Kelly goes, once I puncture the pleura.

Lacerating the lung... yeah... Kellys are blunt, but can still do some damage. Can you think of another (softer?) object that we can slide in there in lieu of our finger to sweep away the lung ? I'm all for keeping my fingers out of there if I at all can.

I like Daiphon's idea!

 

[turkeyjerky]

Imagine the payout you're going to score from the junkie with half a broken needle in his shooting arm abscess.

But your point is interesting.

What would happen if a cop got poked by a needle while searching someone? I'm betting the perp would get charged w/ assault w/ a deadly weapon or something along those lines, maybe a similar standard should apply for medical professionals.

 

[jbar]

How about using the ortho surgical gloves. A lot stronger than even double gloving...

Don't they have those over gloves? I think they are like cotton but sterile. I remember seeing ortho use it in surgeries where they had to manipulate bone ends. You could slip one over your sterile glove for some extra protection. The down side is you might lose some of that tactile feedback from your finger sweep.

 

[Groove]

Honestly, if he were HIV and HCV positive or something like that... I'd use a damn trochar which I usually hate. I ain't touching shattered ribs with my gloved finger shoved in to the hilt, those things are sharp.

If they didn't have one, hell... triple glove?

As for the Kelly technique thing... I usually use one hand, but I grab the kelly mid portion, place thumb over the amount of depth I want to push through, and shove... That way when the resistance is gone, my thumb catches the subq and chest wall and prevents the Kelly from puncturing lung. Works for me.

 

[FDNewbie]

As for the Kelly technique thing... I usually use one hand, but I grab the kelly mid portion, place thumb over the amount of depth I want to push through, and shove... That way when the resistance is gone, my thumb catches the subq and chest wall and prevents the Kelly from puncturing lung. Works for me.

Sounds like a great idea. But I can tell ya from my personal experience, some pleuras are VERY tough and *required* two hands.

Or, I'm just weak

 

[Hamhock]

As for the Kelly technique thing... I usually use one hand, but I grab the kelly mid portion, place thumb over the amount of depth I want to push through, and shove... That way when the resistance is gone, my thumb catches the subq and chest wall and prevents the Kelly from puncturing lung. Works for me.

Some time ago I started pushing through the pleura on non-emergent chest tubes with small, curved hemostats.

Less damage, less risk of organ puncture...and easier to get through tough pleura.

The larger Kelley can then be placed in the small whole and used to open it up for the chest tube.

This doesn't address the rib fracture part of this thread, but it important, IMO, nonetheless. I always cringe when I see a young resident putting weight on a Kelly nearly perpendicular to the chest wall.

HH

 

[TrustMe]

Did one recently with a CT surgeon (it was one of his patients, but he let me do it and he showed me his favorite technique). Went through the usual, incision, blunt dissection, pop through pleura with kelly clamp and then spread to create a good tract. He then had me use the tube with the trochar in it. Curve the tube/trochar to about 45 degrees. Pull tip of trochar back into the tube so that you are just usuing the trochar as a "stylet", NOT to puncture the skin. Once you get the tube/trochar in the chest, sweep with this combo to free any anhesions. Then direct and advance the tube right where you want it. With the tip pulled into the tube you are just advancing with the end of the chest tube, which is not sharp enough to puncture anything. With this technique you can free adhesions, direct the chest tube to exactly where you want it, and avoid putting your finger in the patients chest. I kind of like it.

 

[EMIM2011]

Has anyone ever used these? http://www.ansellhealthcare.com/ProductFiles/cut_resistant_liner_productSheet.pdf