Trauma/chest tube question

[Boatswain2PA]

Wasn't my case, but brought up a question I guess I might not know the answer to so I'd like to ask the EM experts.

Multi-trauma MVA. EMS performed needle decompression in the field. In our very small, very rural ED pt was found to have, among other injuries, significant flail chest on left side (side that was decompressed). CXR showed approx 20% pneumothorax. Patient was desatting, so ED provider (a NP) went for a chest tube.

The NP didn't want to put the chest tube through the (closed) flail chest area which apparently involved the entire lateral chest, so after phone consultation with a trauma surgeon she put it on the midclavicular line where the needle decompression was done. I guess there was also some question about intubating the patient before the flight, even when he didnt improve with the chest tube.

I don't think I would have hesitated to put a chest tube through an area of flail chest. I realize that I would have a greater risk of cutting my finger on a bone fragment while confirming I'm in the thoracic cavity, but I think I would've done that anyway.

Am I wrong? Is the mid-clavicular space an appropriate space to put in a chest tube?

Thanks, in advance, for your answers.

Edited - Found out the provider was a NP, not a PA (not that it matters for this)

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[msgsk]

While I've never done one that way I've read about it. What size tube did you insert? If it's a smaller tube it's reasonable. Hard to say whether or not it's safe to put one in a flail chest without seeing the x-rays...

 

[link2swim06]

I know you aren't suppose to put a chest tube through an area where you already have a break in the skin (i.e. putting a chest tube through a stab wound or a bullet wound is bad form and theoretical higher infection risk).

I'd worry about pushing with the kelly forceps when you make your hole with a flail segement as your target. Sounds like a good way to push a sharp bone fragment into the lung.

I have heard of a mid-clavicular chest tube but never seen it. If I remember you have a higher risk of hitting important stuff going that way. But probably better than stabbing the lung with a broken rib.

 

[dotcb]

I would have put it in the mid axillary line (or somewhere on the side), seen how the patient was, and then intubated the patient if I had any concerns before flying them.

 

[RuralEDDoc]

That tube placement seems less than ideal. When you're placing an chest tube for trauma reasons, the tube is supposed to lie posterior to the lung, so it can drain both air and blood, requiring an axillary placement. An anterior chest tube wouldn't be able to drain blood in a supine patient. In the end it won't really matter, because if the chest tube decompressed the chest in order to stabilize the patient for transfer to a trauma center, then great; the trauma center will then reevaluate and place an appropriate tube.

 

[Boatswain2PA]

While I've never done one that way I've read about it. What size tube did you insert? If it's a smaller tube it's reasonable. Hard to say whether or not it's safe to put one in a flail chest without seeing the x-rays...

Wasn't my case, but if I had to do that I would use a small one. We use very small tubes for peds, why can't we use the same small size ones for adults? It's not like adult RBCs are any bigger than pediatric RBCs.

Chest CT (not sure why they did one) showed about 25% pneumo, large amounts of subq emphysema, and large flail chest (along with fx scapula, clavicle, and multiple T-spine fx). I'm guessing the NP saw the large amount of swelling due to the subq air and flail chest and didn't want to cut through it, but that is just my supposition.

I know you aren't suppose to put a chest tube through an area where you already have a break in the skin (i.e. putting a chest tube through a stab wound or a bullet wound is bad form and theoretical higher infection risk).

I'd worry about pushing with the kelly forceps when you make your hole with a flail segement as your target. Sounds like a good way to push a sharp bone fragment into the lung.

I have heard of a mid-clavicular chest tube but never seen it. If I remember you have a higher risk of hitting important stuff going that way. But probably better than stabbing the lung with a broken rib.

I see your point about the potential bone fragment, but not sure if I'm concerned about that in my environment. First, looking at the CT, I think the lung parenchyma was already compromised. Second, even if I did cause a small(ish) lung lac due to bone fragment, don't think I would care so much. A surgeon is going to have to go clean up anyway, I just want to establish as much air exchange as I can for the 2-3 hours it takes to get them to trauma center.

I would love to hear other's opinion of this?!?

That tube placement seems less than ideal. When you're placing an chest tube for trauma reasons, the tube is supposed to lie posterior to the lung, so it can drain both air and blood, requiring an axillary placement. An anterior chest tube wouldn't be able to drain blood in a supine patient. In the end it won't really matter, because if the chest tube decompressed the chest in order to stabilize the patient for transfer to a trauma center, then great; the trauma center will then reevaluate and place an appropriate tube.

That was my thought. An anterior tube wouldn't be able to drain the blood that I would expect to collect in the thoracic cavity of a wrecked chest like this. It might decompress the pneumo, get them in the plane, and then the hemothorax builds up and collapses the lung in flight. Now I've left the flight nurse without means to decompress.

Has anyone ever seen a (closed) flail chest that they would NOT cut through to place a chest tube?

 

[link2swim06]

I see your point about the potential bone fragment, but not sure if I'm concerned about that in my environment. First, looking at the CT, I think the lung parenchyma was already compromised. Second, even if I did cause a small(ish) lung lac due to bone fragment, don't think I would care so much. A surgeon is going to have to go clean up anyway, I just want to establish as much air exchange as I can for the 2-3 hours it takes to get them to trauma center.

I obviously don't know what your patient or their flail chest looked like but I think you are at a high(er) risk of perforating deep into the lung if you have random non-connected bone fragments laying around.

I have seen a chest tube accidentally inserting through lung parenchyma into the pulmonary artery (ultimately causing death of the patient). And this was done by a senior surgery res and is a blunt object. The lung disease is pretty delicate and bone fragments are sharper. Even on pt's w/o flail chest you generally create a small bruise on the lung where you go in with a chest tube.

And I don't think you will be doing the pt any favor from a gas exchange standpoint if you have created some massive air leak.

 

[EM4Reals]

I have never heard of a flailed chest changing the placement of a chest tube. You still want to go in the exact same location for the patient's safety. With that amount of trauma, you are bound to have a hemopneumothorax and will not be able to remove the blood with a chest tube at the midclavicular line. I've put chest tubes through a flailed segment without difficulty. You should be more concerned about cutting your finger on broken bone fragments rather than hurting the patient.

 

[Boatswain2PA]

I obviously don't know what your patient or their flail chest looked like but I think you are at a high(er) risk of perforating deep into the lung if you have random non-connected bone fragments laying around.

I have seen a chest tube accidentally inserting through lung parenchyma into the pulmonary artery (ultimately causing death of the patient). And this was done by a senior surgery res and is a blunt object. The lung disease is pretty delicate and bone fragments are sharper. Even on pt's w/o flail chest you generally create a small bruise on the lung where you go in with a chest tube.

And I don't think you will be doing the pt any favor from a gas exchange standpoint if you have created some massive air leak.

Again, not my patient, but interesting case that I didn't know the answer to.

I agree higher risk of greater lung damage going through a badly flailed chest than through intact chest wall. I don't know if it's higher risk than taking an anterior, mid-clavicular approach. Especially on the left side, I can see the risk of the tube getting coiled around and knicking something that pumps high pressure.

Have you ever chosen to do an anterior approach instead of going through a flailed chest? Seen anyone do it? I'm not arguing, I'm just trying to expand my toolbox.

I have never heard of a flailed chest changing the placement of a chest tube. You still want to go in the exact same location for the patient's safety. With that amount of trauma, you are bound to have a hemopneumothorax and will not be able to remove the blood with a chest tube at the midclavicular line. I've put chest tubes through a flailed segment without difficulty. You should be more concerned about cutting your finger on broken bone fragments rather than hurting the patient.

Thank you. Do you think you would ever see a (closed) flail chest that was so bad you would take an anterior approach?

 

[Doctor Bob]

You can put in chest tubes anywhere... anterior, lateral, posterior. I've done all 3 on the same patient before. You wouldn't want to put a 24-40 french chest tube with a posterior approach only because it would be awfully uncomfortable. Posterior tubes tend to be smaller (14-20 french). Anterior tubes... just don't hit IMA, but you probably shouldn't be that medial anyways.

Lateral approach is convenient, more comfortable when it's a large bore tube, and easy to standardize the teaching. But it's not the only option.

 

[pseudoknot]

As Doctor Bob said. I usually place percutaneous chest tubes anteriorly. An open tube would be uncomfortable there because there's more muscle to go through, but not a huge deal. I'm surprised the patient wasn't intubated though; flail chests tend to come with impaired respiratory mechanics and severe pulmonary contusions.

 

[DoctorMedic]

I was actually doing some reading on this not long ago after a discussion with an attending. Basically literature (Roberts and Hedges EM Clinical Procedure Guide) and most all resources agree that if you put a tube anywhere in the chest cavity any fluid, air, etc will track to the tube to get out as the pressure will force it into the tube. I have seen the 2nd tube be ant chest by trauma, obviously we usually go for the ant axillary line first. I would say you can always go higher in the axillary area, doesn't have to be between 4-5 or 5-6. Can go 3-4 in that line and angle the tube towards the diaphragm. Granted not the most comfortable but will get the job done in the long run. Also for that much trauma after the tube I would intubate before flight. Much better odds of a successful tube without undue stress to the patient.

 

[Boatswain2PA]

Thank you everyone. I just want to re-iterate, again, this was NOT my patient. I am just gleaning any learning I can from the case.

I don't understand why there was any discussion about intubating the patient, and I don't know why they did the chest CT in our shop. The former seems like a foregone conclusion, and the latter seems like a waste of time for this patient in my shop. But again, I wasn't there, the NP was.

 

[RustedFox]

Didn't read the entire thread (I will, I'm tired, goodnight), but with the Thal-Quick (or equivalent) chest tube kits, you can slide a tube wherever you want. In there, like swimwear.