Chest tube insertion – Pigtail

Pigtail Catheter Insertion Procedure and Pearls

Dr. Paul Frankish & Dr. Matt Greer

 

  1. Obtain informed consent if possible, obtain all supplies needed, have drainage system opened and ready to go.
  2. Sterile prep, drape, gown/glove.
  3. Identify triangle of safety (5th IC, mid axillary, pectoralis).
  4. Anesthetize skin, subcutaneous, rib, intercostal, and pleura. Consider procedural sedation.

PEARL – May need up to 20 cc of local, consider refreezing with larger spinal needle, withdraw until the air bubbles stop to freeze the pleura.

5. Insert large “seeker” needle at desired IC space, with fluid filled syringe attached, withdraw as you go.

PEARL – Mark the depth where you hit air bubbles for when you dilate the tract

6. Slide over superior aspect of rib and stop when you withdraw air bubbles/fluid.
7. Detach syringe and insert guide-wire through needle. There should be no resistance. Only about 10 cm inside the thoracic cavity is required. Remove needle while leaving the guide-wire in place.
8. Make a small incision with 11-blade alongside guide-wire, then dilate needed depth, then insert pigtail with obturator over wire to appropriate depth.

PEARL – Do not forget to remove the obturator before attaching to drainage system.

9. Insert as far as possible until resistance is felt to ensure all fenestrations are within the thoracic cavity.

PEARL – You can always pull it back out if it’s in too far.

10. Attach 3-way stopcock, tubing extension, then to either Heimlich valve or underwater seal/wall suction.
11. Suture in place as per usual chest tube technique. Ensure dressing optimizes skin seal (sticky/occlusive).
12. Confirm placement with chest x-ray.

 

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An approach to removing hair tourniquets

Getting out of a hairy situation – an approach to removing hair tourniquets 

Resident Clinical Pearl (RCP) May 2020

Renee Amiro – PGY3 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. Kavish Chandra

 

A two-month-old male presents with his mother to the emergency department with two tightly wound hairs around his fourth and fifth toes. He is visibly upset and crying excessively. His mother says that his toes looked like this when he woke up this morning. He is otherwise well and has had his two-month immunizations.

His toes look like this:

 

 


Hair tourniquet syndrome

Definition – a tightly wound hair, thread, rubber band that is wrapped around an appendage and causes impaired blood flow.

Why this is bad – the constriction causes edema which restricts venous blood flow causes more edema which then impedes arterial blood flow and that can cause ischemia and if left undetected could cause amputation.

Most common appendages involved – Toes, external genitalia, fingers

Most common presenting symptom – excessively crying young child or swollen appendage found by mom or dad.

 

Management

Goal is to remove the restricting band ASAP!

Remember to treat pain! Using emla gel on the digit prior to any manipulation and use other analgesics as you deem appropriate. Remember the use of sugar for pain management in babies.

In all management types- ensure you have gotten all of the hair and have released the constricted band completely.

  1. Try and unwind the hair!
  • Works best if caught early
  • You can use a cutting suture needle to try and get underneath the hair and release it.

 

  1. Depilatory Cream
  • Apply Nair to the affected toe and allow 2-8 minutes to see if the hair dissolves.
  • Should not be used on open wounds and can cause skin irritation.
  • Does not dissolve cotton, polyester or rayon threads.

 

  1. Dorsal Slit Procedure (for digits)
  • Do a slit on the dorsal surface along the long axis of the digit through the area of constriction down to the bone to ensure release of tourniquet.
  • Lateral aspect contains nerves and blood vessels and should be avoided. You may cut the tendon doing a dorsal slit along the long axis- but you won’t affect function of the digit.
  • Ensure that the patient has close follow up to ensure healing and complete resolution of the tourniquet.

 

The bottom line

  1. Think of this diagnosis and LOOK for it in a young child brought to the ED with “excessive crying”
  2. Ensure adequate pain management prior any invasive removal of the tourniquet.
  3. Move quickly down the list to the dorsal slit procedure (for digit) if deeply embedded hair with significant edema or tissue compromise.

 

Copyedited by Kavish Chandra

 

References

Lin, Michelle 2012. https://www.aliem.com/trick-of-trade-hair-tourniquet-release/

Fox, Sean 2015. https://pedemmorsels.com/hair-tourniquet/

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What we missed in FOAM October 2017

Welcome to SJRHEM’s newest feature, “Best of FOAM”. This is a quick curated list of the best free open access medical education the internet has to offer!

Subscribe to our twitter feed for regular updates and enjoy!

 

EM procedures

 

Clinical summaries

 

Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick

 

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