Tag Archives: chest tube

Chest tube insertion – Pigtail

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Pigtail Catheter Insertion Procedure

EMSJ Faculty Pearl

Dr. Paul Frankish & Dr. Matt Greer

Updated April, 2023

See Video of Pigtail Catheter Insertion Here

Equipment Update: 

Adults: Trauma carts should be stocked with 28Fr, 24Fr, 20Fr standard chest tubes and 14Fr pigtail catheter kits. It is recommended that we discontinue stocking larger sized chest tubes (32Fr, 36Fr) and Cook 9Fr pneumothorax set with metal trochar/needle.

Pediatrics: PALS carts should be stocked with 10Fr seldinger kits, 14Fr pigtail catheter kits and 20 Fr standard sized chest tubes.

  1. Obtain informed consent if possible, obtain all supplies needed, have drainage system opened and ready to go.
  2. Confirm 3-way stopcock attached to tube, then insert obturator through this 2. Sterile prep, drape, gown/glove.
  3. Identify triangle of safety (5th IC, mid axillary, pectoralis). – or use PoCUS to guide site safety and depth (DL)
  4. Anesthetize skin, subcutaneous, rib, intercostal, and pleura. Consider procedural sedation.

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.

Note the depth when you get 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 guidewire 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 guidewire, then dilate to required depth with dilator, then insert pigtail with obturator over wire to appropriate depth.

Remove the obturator once tube is within pleural cavity, then advance pigtail into chest

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

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

10. Attach tubing extension, then to either Heimlich valve or underwater seal/wall suction.

Heimlich valve function is unidirectional. Attach blue end to chest tube

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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Tube Thoracostomy

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Saint John EM Rounds – February 2021

Dr Crispin Russell

Thoracic Surgeon, Dalhousie University, Saint John

 

 

 

Trauma Rounds Summary:  January 19 2021 “Chest Tube Management in Trauma – Insights from a Thoracic Surgeon”

Summary – Dr. Andrew Lohoar

Major take home points:

 

  • Most common complication with insertion is advancing tube too far.

  • Consider placing tube if pneumothorax is > 10%, lower threshold if transporting patient from peripheral hospital.

  • Use 28 French tube for most cases

  • Direction you puncture chest wall is generally direction chest tube will follow

  • Bigger skin incision may make procedure easier

  • “Corkscrewing” or twisting chest tube while placing it, helps ‘feel’ where it is in the chest cavity (avoids advancing too far)

  • Post-chest tube insertion CXR is critical to identify placement issues

  • Use large volume of local anesthetic (20+ cc) – try to infiltrate parietal pleura

  • Consider infiltrating prior to setting up your tray, allowing more time for anesthesia

  • Consider holding Kelly clamp with one hand when puncturing pleural, to protect from pushing tip to far into chest. Spread clamp parallel to ribs

  • 0 Silk is still preferred for securing chest tube

  • Consider tying an ‘air knot’ 1 cm above skin when securing tube, allows easier adjustment later

  • Secure chest tube connections with longitudinal taping – stronger and can see joint

  • U/S can be used to assist with placement

  • Always assess for chest tube functioning post-procedure

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Trauma Reflections – December 2018

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Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

Major points of interest:

A)  TXA – “When did this MVA actually happen?”

Only 75% of cases receiving TXA are receiving it within 3 hours of injury. And only ½ of theses cases are having the drip started.

CRASH study found patients receiving TXA after 3 hours do not benefit.

B)   Bleeding on warfarin

If emergent reversal of anti-coagulation from warfarin is needed, vitamin K (5-10mg) should be given IV (not PO), along with PCC.

C)  Trauma transfers from outside of our region in the post TTL era..

Consultants accepting transfers from other regions through NB trauma line may request that patient stop in ED first for evaluation/imaging prior to transfer to floor or ICE.

The consultant should make every effort to evaluate their patient on arrival to ED  

Expectation is that TCP and/or consultant clearly delineate their plan with ED charge MD.   

E) Matthew 4:1:1  “Man shall not live by [RBCs] alone”

I might not have gotten that one quite right, but the MTP policy follows a 4:1:1 rule – after 4th unit of PRBCs, give a unit of platelets and FFP.

F) This guy is bleeding all over my triage room!

Patients occasionally “self-present” to triage with significant injuries or a history of a high energy MOI. The most efficient way to mobilize resources is to have the triage RN call a “Trauma CODE”.   

G)  Analgesia in pediatric population

Pain management in pediatric population is often challenging. If IV access is delayed consider alternative routes – intranasal fentanyl 1.5 ug/kg using MAD (mucosal atomizing device).

H)  May the hoses R.I.P.

Chest tube sizes 36 F and 345F are now no longer being stocked on chest tube cart.

I)     Post-intubation sedation

Post intubation sedation and analgesia can be challenging. Key is to avoid starting medications that could potentially drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.

Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of continued agitation.

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Trauma Reflections – October 2018

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Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

 

Major points of interest:

 

A)  Intubated patients should not need restraints..

Post intubation sedation and analgesia can be challenging. Key is to avoid starting medications that could potentially drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.

Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of continued agitation.

 

B)   But what about this guy with the BP of low / really low?

Consider “vitamin K” – ketamine – can augment BP in patients who are not catecholamine depleted.

 

C)  Trauma patients you know will require consultants

When services are known to be required for patients prior to arrival (intubated, critical ortho injuries, penetrating trauma, transfers etc.) call a level A activation – consultants should meet patient with you. Give the consultants notice when patient is 15 minutes out.

Required consultants need to attend to critically injured in a timely fashion. Escalate to department head or chief of staff if there is unreasonable delay.

View the SJRHEM Trauma Page for list of definitions including Trauma Team, Activation Levels etc

 

E) Managing the pediatric airway – adrenalizing for all involved

Pediatric trauma is the pinnacle of a HALF (high acuity, low frequency) event. Team approach is key. Get out the Broselow tape.

Bradycardia with intubation attempts is not infrequent in youngest patients. Consider atropine as pre-med if  < 1 year of age or < 5 years of age and using succinylcholine.

 

F) MTP

Do not forget platelets and plasma if onto 4th unit of PRBCs – 4:1:1 ratio.

 

G)  Where is this patient being admitted?

Not to the hospitalist service, that is where!

Patients with significant injuries, but not needing immediate surgical intervention, should be admitted/observed in ICE x 24 hrs. Department head and/or chief of staff are available to assist if needed.

 

H)  Chest tube types and sizes

Pigtail catheters for traumatic pneumothorax are effective, less painful and are gaining favour as an alternative to traditional chest tubes. As for sizes, there is likely little benefit for 36F over 32 F catheters – probably time to retire these monsters from the chest tube cart.

I)     Why do bedside U/S if patient about to go to CT?

Chest scan might prompt chest tube placement prior to CT if pneumothorax is identified. Although identifying blood in the abdomen prior to CT may not change your management – it may prompt an earlier call to general surgery.

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Trauma Reflections – August 2018

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Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

 

 

Major points of interest:

 

A) Blood is important stuff…so keep track of it.

Recent ATLS guidelines are suggesting switching to blood for resuscitation after one litre crystalloid bolus, not two. We will be using blood more often and it is important to keep track of amount ordered and infused. Give clear orders, document, and send any unused units back to transfusion medicine.

 

B) Analgesia/anti-emetics prior to leaving for diagnostic imaging

Moving on/off DI tables can increase pain or provoke nausea in some patients.

 

C) Who put that thing there?

If you decide to put something into your patient, such as a chest tube or ET tube, then write a procedure note, including details of placement confirmation.

 

D) Trauma patients you know will require consultants

When services are known to be required for patients prior to arrival (intubated, critical ortho injuries, penetrating trauma, transfers etc.) call a level A activation – consultants should meet patient with you. Give the consultants notice when patient is 15 minutes out.

In pediatric traumas that cannot be managed locally use the NB Trauma TCP to coordinate transfers to IWK.

 

E) Yo-yoing to DI for yet another film

“Pan-scanning” a younger patient can be a difficult decision, but if there is a high energy MOI and indication for spine imaging, CT scan is the superior imaging choice.

 

F) Pregnancy tests for everybody

Do not forget this in ‘older’ pediatric age group.

 

G) “Moving all limbs”..

..is NOT an acceptable documentation of exam findings in a patient with suspected neurologic injury. Thorough exam to detect any deficits is needed for neurologic baseline and for comparison later. Dermatome level of sensory dysfunction, key muscle group strength (0-5 scale) and anal sphincter tone should all be recorded, with time of exam.

 

H) Severe traumatic brain injury

Remember the CRASH 3 study – adult with TBI < 3hrs from time of injury.

 

I) Motorcycle + cocaine + EtOH + no helmet…

Equals an agitated head injured patient very difficult to sedate after intubation. Consider fentanyl infusion in addition to sedation infusion.

 

 

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Trauma Reflections – June 2018

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Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

 

 

Major points of interest:

 

A)  Should that be bubbling like that?

Chest tube placement is a critical procedure in managing trauma patients – successful placement can be challenging, complications are common. Post-procedural imaging and check of chest drain system should determine adequate positioning/effectiveness. Check for fluctuation (tidaling) of fluid level in water seal chamber.

 

B)   Nice intubation…but why is his BP now70?

Post intubation sedation and analgesia infusions are superior to push dosing, but should be titrated up slowly to effect. Avoid starting medications that could potentially drop blood pressure at very high infusion rates – yo-yoing BP is not good for damaged neurons.

See attached NB consensus statement for suggested medications and dosages.

FINAL Consensus statement – RSI+ – July 2018

C)  Crystalloid choice in burns

(Warmed) Ringer’s lactate is the preferred crystalloid for initial management of burns patients. And probably all trauma patients for that matter.

 

D)  TTA log sheets – numbers are only slightly better

Ensure qualifying traumas have activations, and TTA log sheets are filled out. Don’t forget transfers should have activations as well.

When services are known to be required for transfer patients (intubated, critical ortho injuries etc.) call a level A activation – consultants should meet patient with you.

Remember, ED length of stay < 4hours is significantly higher with trauma activations (60% vs. 30%), so it is to our advantage to identify these patients immediately on arrival.

 

E) Propofol infusions in pediatric population

This in still a no-no in patients < 18 yo. Single doses for procedure is fine, but for maintaining sedation choose something else.

 

F)  “Moving all limbs”..

..is NOT an acceptable documentation of exam findings in a patient with suspected neurologic injury. Thorough exam to detect any deficits is needed for neurologic baseline and for comparison later. Dermatome level of sensory dysfunction, key muscle group strength (0-5 scale) and anal sphincter tone should all be recorded, with time of exam.

 

G)  We don’t talk anymore..

There should be TTL to TTL handover at shift change if the trauma patient still resides in our ED. Even if consultants are involved.

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