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The Procedural Pause by James R. Roberts, MD,
& Martha Roberts, ACNP, PNP​

​Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are the team behind The Procedural Pause.

The blog will focus on procedures that emergency physicians, residents, and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

This blog conveys personal opinions and experiences, and application of the information here remains the professional responsibility of the clinician. Tthis blog is not intended to dictate standard of care, but is a clinical guide, not a legal document. Do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Please share your thoughts about the Roberts' posts.

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Thursday, August 1, 2019

Toe jam injuries are extremely painful because the feet have sensitive parts and a delicate anatomy. Patients, especially women, care about cosmetic results. EPs should consider the emergency concerns of foot wound closure and cosmetic results when attempting repair. More importantly, patients with neuropathies, diabetes, and vascular diseases warrant close attention to detail to prevent complications. High-risk patients can develop serious infections, which could result in the loss of a toe or limb. It might be excessive to call a plastic surgeon to consult on a foot wound, but it may be appropriate to consult podiatry or vascular.

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A simple toe jam injury with a linear laceration. Photo by M. Roberts.

Toe jam injuries do not always require radiographic imaging. Simple cuts and lacerations should be irrigated and elevated in the emergency department. Crush or severe impact injuries need three or four plain-film radiographic views of the foot and toe to rule out fractures. Pay particular attention to fractures to the fifth metatarsal, navicular bones, and joint spaces, finishing your exam using a step-wise approach. (J Emerg Med. 2002;22[2]:163.) The tendons and ligaments should be tested for strength and mobility. Cleaning the feet with soap and water is critical, as is using chlorhexidine prep or Betadine swab before anesthetizing the area. Soaking the foot in a bath of Betadine is discouraged.

Studies have shown that normal saline is as effective as Betadine in decreasing infection rates in simple traumatic wounds. (Wound Med. 2016;15;1; http://bit.ly/2Iq22Hg.). Simple tap water has been proven to be just as effective as sterile saline for wound irrigation. (Acad Emerg Med. 2007;14[5]:404.) EMN author Dan Runde, MD, had an article about this: "Time to Tap Out? Water or Saline for Wound Irrigation?" EMN. 2016;38[7]:21; http://bit.ly/2Iq2RzQ.

The running suture plays an extremely useful role in interwebbed toe injuries. Suture knots are itchy, and can be painful during the healing process. Socks often catch on the knots, and can easily dislodge their placement. Knots may also interfere with wound healing if they are too close together, too loose, or too tight. Retained moisture can be the enemy when it comes to foot wounds, especially for those with diabetes or other foot issues.

Our video demonstrates proper use of the running sutures within the web space.

The Approach

  • Toe laceration repair using the running suture.

The Pause

  • It is helpful to give an oral medication such as ibuprofen or acetaminophen before starting this procedure. Elevate and ice the injury to decrease the pain from the lidocaine injection.
  • Do an excellent exam, and don't forget to explore the wound for tendon or ligament damage.

The Procedure

  • Localize the acute injury, and survey for other possible injuries. Flex, extend, and palpate the foot and toes.
  • Order appropriate imaging based on exam and history.
  • Clean the area around the laceration with Betadine or chlorhexidine.
  • Anesthetize the area. A local infiltration of 1% lidocaine is sufficient. Always use a bicarb buffer to minimize the pain of the injection.
  • Allow a few minutes for the anesthesia to take effect.
  • Inspect the area with good lighting and magnification to check for any foreign body. Irrigate with tap water or normal saline.
  • Use a 4.0 or 5.0 Prolene PS-2 or PS-3 suture (nylon is also acceptable) to close the wound using the running suture technique. Subcutaneous sutures may be used. Prolene is the least secure when dealing with knot security, but it has the best tensile strength. It also has the least tissue reactivity (compared with nylon and silk) and handles well. (Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th edition. Philadelphia: Saunders/Elsevier, 2014.)
  • Reinforce sutures with Steri-Strips.
  • Topical bacitracin has not been proven effective. It often keeps the area too moist, and prevents proper wound healing, causing scarring.
  • Have the patient follow up in seven to 10 days for suture removal.
  • Recommend crutches and non-weight-bearing for the first few days along with elevation and ice. Use ibuprofen or acetaminophen for pain control. Antibiotics are not indicated.
  • Refer to podiatry if needed.

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Post-procedure non-occlusive dressing. Photo by M. Roberts.

Antibiotics for Patients with Diabetes

Should you give antibiotics to patients with simple lacerations who are diabetic? Maybe. Approximately two to five percent of simple hand lacerations become infected, regardless of age, gender, diabetes, prophylactic antibiotics, and closure technique. (World J Emerg Med. 2015;6[1]:44; http://bit.ly/2IqSXxH.) Lower-extremity injuries and lacerations larger than 5 cm may have a higher rate of infection in patients with diabetes. (Emerg Med J. 2014;31[2]:96; http://bit.ly/2ItreN3.). Antibiotic treatment in this group should be considered depending on the history, exam, and extent of injury.

Monday, July 1, 2019

​Ocular punctal plug removal is a straightforward procedure easily completed in the emergency department. Serious complications from punctal plug insertions are rare but sometimes seen.

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Left: A punctal plug in the upper lacrimal duct of the right eye, allowing for moisture balance from tear production. Right: The tiny punctal plug after it was removed. Photos by M. Roberts.

Punctal plugs are placed in some or all of the lacrimal ducts by an ophthalmologist to treat chronic dry eye, and can be permanent or dissolvable. Plugs typically stay in place for three months or longer. (Am J Ophthalmol. 2007;144[3]:441.) The most common complications are localized irritation and dislodgement with foreign body sensation and epiphora within the first 48 hours. Other complications include corneal abrasions, conjunctivitis, dacryocystitis, and canaliculitis.

Call the ophthalmologist who placed the punctal plugs or the on-call ophthalmologist if a patient presents with related complaints. The ophthalmologist may have needed to dilate the lacrimal ducts, which can cause irritation in the first 24-48 hours. Typically, proparacaine or tetracaine can soothe the eyes during the initial transition. It is important to know the day and time of the original procedure to determine if the irritation is from insertion or long-term use.

The plugs can cause deleterious effects such as blurry vision if epiphora occurs. Patients may also have continued irritation or dislodgement of the plug. If the plug is loose, it can fall into the eye and cause minuscule corneal abrasions. It is important to ask the patient or ophthalmologist which type of punctal plug was placed in the case of dislodgement. If the foreign body is retained in the eye, it may need to be removed, or it may dissolve. Continued irritation can lead to pain and rarely conjunctivitis.

Patients may request that you remove the plug regardless of the associated complication. If mild or moderate conjunctivitis is present, antibacterial ointment such as erythromycin and lubricating drops can be placed in the eye for three to five days. Close ophthalmological follow-up is advised.

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Silicone punctal plug compared with standard tweezers. Photo by M. Roberts.

The Approach

  • Consult the ophthalmologist.
  • Careful identification and removal of ocular punctal plug using a slit lamp and tweezers.
  • Treatment of any underlying complications such as infection, pain, and irritation.

The Pause

Be sure to wear gloves and use a fresh pair of tweezers to remove the punctal plug. They are best removed under a slit lamp if available.

The Procedure

  • Determine the insertion date and type of the punctal plug and pertinent medical or ocular surgical history. Discuss medications being used for dry eye or other concerns.
  • Consult the ophthalmologist.
  • Once the decision is made to remove one or more of the plugs, position the patient in an upright sitting position.
  • Use good lighting to identify the plug, preferably a slit lamp.
  • Use a pair of tweezers to grab the edge of the plug.
  • Remove the plug and examine the lacrimal duct.
  • Treat underlying eye irritation (foreign body sensation or corneal abrasion) with topical proparacaine, tetracaine, or erythromycin or other ocular antibiotics, if indicated.
  • Suggest that the patient use lubricating drops such as Systane or propylene glycol for dry eye.
  • Patients may massage the empty lacrimal ducts with clean hands to help with tear production.
  • Warm or cold compresses may be comforting.

 PP-punctal plug-removal.jpg

Watch a video of punctal plugs removal.

The Cautions

  • Typically, minor or mild eye redness or irritation will resolve once the problematic plug is removed, and medications are not required.
  • Serious eye infections are rarely associated with punctal plugs. Investigate this issue cautiously, if present.

Sjögren's syndrome is an autoimmune disease that can cause dry eye and dry mouth. Patients with this syndrome can develop canaliculitis and other more serious eye issues. Ask patients about this underlying condition if you note serious complication within 30 days of punctal plug placement.

Infections Related to Punctal Plugs

All foreign objects have the potential to cause an infection, and a biofilm can grow on the surface of implanted objects. (Live Science. Dec. 21, 2016; http://bit.ly/2HEGOnk.)

Conjunctivitis and dacryocystitis are the most common infections related to punctal plugs. This can spread into the eye. Bacterial biofilms with colonization of Staphylococcus haemolyticus and Candida tropicalis have been discovered in patients. (Jpn J Ophthalmol. 2000;44[5]:559.) Punctal plug occlusion may also cause canaliculitis, which can result in excessive tearing, white or pus discharge, red eyes, and tenderness. One such case of canaliculitis caused by Actinomyces odontolyticus was noted in the case of a 63-year-old patient with Sjögren's syndrome. (Nippon Ganka Gakkai Zasshi. 2002;106[7]:416.) It was successfully treated with removal of the plug and topical antibiotics.

Canaliculitis may be associated with the type of punctal plug. Some studies show that dissolvable plugs can cause an increased risk of delayed complications, such as canaliculitis. One patient with intracanalicular dissolvable plugs had a slow-growing mass causing canaliculitis three years after placement. (Ophthalmic Plast Reconstr Surg. 2009;25[5]:413)

Complications were examined in a larger retrospective case study of 28 patients with permanent plugs. Eighteen developed inflammation, 17 with canaliculitis and one with dacryocystitis. Only 10 patients had no inflammation. (Ophthalmology. 2006;113[10]:1859.e1.) In general, punctal plug complications need close outpatient monitoring, possible removal, and potentially topical or oral antibiotics if infection occurs.

Jim Weighs In

If the patient has all four lacrimal ducts plugged and excessive tearing is present, it may make sense to remove only the top two plugs. This will allow for some tearing to remain without the epiphora. Discuss all plans with the ophthalmologist because he will know the patient and the long-term plan.

Martha Weighs In

It's easy to see the plugs in place. Make sure you hold the tweezers tightly once the plug is grasped so you do not drop it into the patient's eye. Show the patient the plug once it is removed, and say, "I have it right here," to provide reassurance.

Saturday, June 1, 2019

Dozens of pharmaceutical commercials about dry eyes play on television or the radio. Ophthalmologists often use punctal plugs, also called lacrimal duct plugs, for this diagnosis.

Punctal plugs are tiny devices that fit snugly in the tear ducts or puncta of the eye. The plug completely blocks the duct and prevents tears from draining. This allows the moisture in the eye to stick around longer and lubricate the eyes. Patients rarely have major complications from the plugs, but they can fall out or slip out of position.

Patients with dry eyes may have chronic aqueous tear deficiencies or have other ocular issues such as keratoconjunctivitis, keratitis, or recurrent corneal erosions. They may try artificial tears, but these can be cumbersome and expensive. Studies have suggested using the plugs as a simple and effective alternative for dry eyes. (Cornea. 2002;21[2]:135; http://bit.ly/2DuuCo5; Am J Ophthalmol. 2001;131[1]:30; http://bit.ly/2XBM5m0.)

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A punctal plug.

Three types of plugs are available—collagen, silicone, and intracanalicular—and it's important to know their basic differences. All are placed by an ophthalmologist, and the lacrimal ducts occasionally need to be dilated during placement. Sometimes, the plugs fall out or loosen. Collagen plugs dissolve over time, and silicone and intracanalicular plugs last longer. Patients usually have silicone plugs, which look like flat white discs sticking out of the lacrimal duct; intracanalicular plugs extend into the duct and cannot be seen on the surface.

Extreme tearing, canaliculitis, and dacryocystitis are associated with these plugs. They can also migrate proximally into the lacrimal ducts. If the plugs become painful, irritated, or infected, an ophthalmologist may need to remove them surgically. (Ophthalmic Plast Reconstr Surg. 2001;17[6]:465; http://bit.ly/2UXbeLe.)

When a patient presents to the ED with visible punctal plugs, he may be experiencing irritation and ask you to remove them. Check the position of the plugs, and then call the ophthalmologist to discuss if possible. He may suggest attempting to push the plug back in place, which is easily done with a cotton swab and some patience. Do your best to keep the plugs in place unless they are causing severe side effects.

Minor symptoms and foreign-body sensation is normal for the first 24 hours after insertion. The lacrimal ducts can be sensitive from dilation and may need lubricating drops or 12-24 hours of ocular numbing drops. Patients may complain of mild ocular pruritis and burning, mild to moderately red conjunctiva, and foreign body sensation. Excessive tearing with punctal plugs is normal and expected. Reassure the patient that this will pass.

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Watch this attempt to reposition a punctal plug.

It's important for physicians to be able to detect plug loss and reposition plugs if indicated. Next month, we will review common side effects and show you how to extract them.

Wednesday, May 1, 2019

Bedside ultrasound can be useful for identifying lung structures and assisting with chest tube placement. It can also be used to identify a pneumothorax and confirm chest tube placement post-procedure. Practice looking for signs, and make sure you can identify them in normal pediatric and adult patients. You may still need additional imaging such as chest x-ray and CT to confirm the diagnosis, but US yields immediate and accurate results.

Check first for lung sliding, a simple yet convincing finding on US confirming that the lung is inflated. A thin, white line will be seen, which highlights the lung's pleural lining. It may appear shiny or shimmery, and will move back and forth subtly as the patient breathes. Monitor this for a few breath cycles to confirm. The absence of this feature indicates a pneumothorax. You may also see a comet tail, a special form of reverberation artifact.

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Lung sliding and comet tail artifact identification are valuable US skills. Dulchavsky, et. al., performed a prospective evaluation of the sensitivity and specificity of thoracic US in detecting pneumothorax by looking for lung sliding and comet tail artifacts against chest x-ray. A total of 382 trauma patients were examined, and US confirmed 37 of 39 pneumothoraces. (J Trauma. 2001;50[2]:201.) This was 95% sensitive. CXR was completed after US and also confirmed all pneumothoraces.

The authors noted that two pneumothoraces were missed on US because subcutaneous air did not allow visualization of lung sliding. The true-negative rate was 100%. The authors also concluded that a FAST exam should include the thorax to facilitate early and accurate diagnosis of pneumothorax. This could assist with timely procedures, consultation, transfer, and treatment.

Studies have also shown that US may decrease the need for CT in diagnosing pneumothorax. A retrospective study by Lichenstein, et al., examined how chest x-ray can miss pneumothorax, suggesting that CT may be indicated to confirm the diagnosis. (Crit Care Med. 2005;33[6]:1231.) They hypothesized, however, that US may be an alternative method to diagnose pneumothorax. Pneumothorax was diagnosed if lung sliding could not be seen. Further testing with CT was completed to confirm the diagnosis. The absence of lung sliding was 100% sensitive and 78% specific for pneumothorax. (Crit Care Med 2005;33[6]:1231.)

US, CXR, and CT

CXR and computed tomography have been the gold standard for diagnosing pneumothorax. The literature suggests, however, that bedside US may be superior. A study by Wilkerson and Stone examined 606 trauma patients and found that lung US was 86-98% sensitive and  97-100% specific, while CXR was only 28-75% sensitive and 100% specific. (Acad Emerg Med 2010;17[1]:11; http://bit.ly/2JFFgxv.)

Only blunt trauma patients were included and the study was not randomized, but US was still noted to be far superior to traditional CXR for detecting pneumothorax. US, however, may not be useful in other patients depending on presentation and history. US may miss other traumatic injuries that could be seen on CXR and CT, which remain the gold standard for pneumothorax and other lung abnormalities.

The Approach

  • Use bedside US to examine the lungs and pleural and chest wall structures.
  • Evaluate for pneumothorax or other abnormalities.
  • Use bedside US for diagnosing pneumothorax and chest tube insertion and confirmation.
  • Continue to use CXR or even CT to confirm diagnosis and placement or additional concerning diagnoses, especially in trauma cases.

The Procedure

  • Position the patient at a 45- to 90-degree angle. Supine position may be more difficult when identifying structures.
  • A high-frequency linear probe should be used to look for pneumothorax. The indicator marker should point cephalad, but it is important to be between the rib spaces.
  • Position the linear probe at the midclavicular line, second intercostal space.
  • Examine the unaffected side first, and find lung sliding on ultrasound.
  • Always examine this upper anterior portion of the chest. Air in the pneumothorax will rise to the top of the chest, causing the lung to sink downward into the lung cavity.
  • Examine the affected side and compare it with the unaffected side.
  • Lung sliding will appear bright and white. Subtle movement of this line will be observed.

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Watch a video demonstrating lung sliding using US.

The Cautions

  • Be sure to practice on as many people as possible so you have a firm grasp of what's normal before applying it to patients.
  • Do not hang your hat on the solitary diagnosis of pneumothorax in blunt chest wall trauma. Obtain a CXR or proceed with CT scanning to rule out other life-threatening issues.

Monday, April 1, 2019

Seventy-five percent of trauma injuries involve some kind of thoracic insult, a quarter of which need a procedural intervention like a chest tube. (Surg Clin North Am 2007;87[1]:95; http://bit.ly/2HaoX90.) Long-term illness, lung disease, and post-operative complications may cause pleural effusions or a pneumothorax, so treating these conditions quickly can significantly decrease patient morbidity and mortality. 

Other indications for chest tube placement include:

  • Trauma: Pneumothorax, hemopneumothorax, or tension pneumothorax
  • Long-term illness: Pleural effusion (cancer, pneumonia)
  • Infection: Empyema, purulent pleuritis
  • Post-surgery, especially after lung, heart, or esophageal surgery
  • Bronchoscopy

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A CT showing a chest tube in the right lung and pneumothorax in the left lung from trauma. Scan courtesy of Clinical Cases.

Inserting a chest tube is literally hit or miss. If you miss, you may seriously compromise the outcome, so you need to embrace a few simple concepts: know your landmarks, know your technique and tools, and know the cautions and what can go wrong.

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This 49-year-old morbidly obese woman had a spontaneous pneumothorax four days after elective bronchoscopy. Note the misplaced pigtail catheter in the subcutaneous tissue to the left of the fifth intercostal space on the right side of the patient's rib cage. The standard approach was used for this insertion without success.

The Basics

Chest tube insertion should be well-rehearsed and instinctive. You should not hesitate to insert a life-saving tube into a pleural cavity immediately to drain air, blood, bile, or pus. Obtaining a thorough history and chest x-ray is absolutely pivotal to your diagnosis. Know your landmarks before insertion: the fourth and fifth intercostal space and the anterior-axial line. Go up and over the rib as you insert chest tubes. Avoid the lower rib margin to prevent injury to the neurovascular bundle.

You can use one of several tube thoracostomy techniques. Most clinicians prefer standard or classic insertion, that is, blunt dissection (incision, Kelly clamp, finger placement, tube placement). Others may prefer the Seldinger technique using pigtails, but these are usually reserved for pneumothorax only. Pigtails can be placed anteriorly or laterally. It may be difficult to place them laterally in obese patients.

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Use ultrasound to identify landmarks. Find the space between the fourth and fifth ribs. Chest wall anatomy should be confirmed before placement to minimize complications. Use a pen to draw out the safe zone to assist with placement. Photo by Martha Roberts.

Insertion Devices and Techniques

  • Classic approach, blunt dissection
  • Seldinger approach, pigtail insertion
  • Trocar insertion
  • Handheld insertion device such as the Reactor
  • Needle thoracostomy

The Trocar

An alternative method utilizes blunt or sharp trocar insertion. These devices are metal or plastic obturators with a sharpened or blunt tip and a hollow tube. The trocar method requires first making an incision in the same place as for the classic technique. A Kelly clamp may or may not be used. The trocar is blindly advanced to the pleura and then forced through the pleura into the chest cavity. The obturator is removed, and the chest tube remains in place. But is it safe to use a trocar chest tube?

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Sharp trocar tips and trocar storage tubes. Photos by Martha Roberts.

Medscape notes that targeted guidewire (pigtail) and trocar-guided placement are considered high risk for complications in the ED, and that the standard or classic technique should be used for emergent thoracostomy. ("Tube Thoracostomy." Nov. 16, 2018; http://bit.ly/2EiYfZ2.) One study noted that even experienced respiratory physicians and thoracic surgeons may overpenetrate the trocar and cause visceral injuries. (Thorax 2010;65[1]:5.)

Trocar insertion techniques may be valuable if there is extensive chest trauma or multiple broken ribs and a risk to the provider entering the chest cavity with an unprotected finger. Trocars may also be useful in morbidly obese patients or in rural settings with limited resources.

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Have your setup with Pleur-evac and suction ready to go before becoming sterile or making an incision. Photo by Martha Roberts.

Trocar Safety

Four of seven reports in a meta-analysis of trocar insertion safety concluded that the technique was associated with a significantly higher rate of tube malposition and complications. (Interact Cardiovasc Thorac Surg 2014;19[1]:125; http://bit.ly/2Sv5F0b.) One of the retrospective reviews in the analysis found the rate of tube malposition to be similar in groups using the trocar and blunt dissection. The authors, however, abandoned the trocar technique because of severe complications like lung and stomach injuries. Other studies in this meta-analysis showed that the trocar was "as safe as and even more effective than blunt dissection alone." A randomized prospective study in cadavers also included in the meta-analysis found fewer complications with blunt tip trocars than sharp ones.

The authors advised avoiding the blind trocar technique for chest tube placement in adults because of the higher incidence of malposition and complications. They recommended using the blunt dissection technique with digital exploration of the pleural cavity before chest tube placement. One of the studies, however, found that blunt dissection into the pleural space, followed by the use of a trocar to direct the chest tube, was as safe as and more effective than blunt dissection alone. (J Cardiothorac Surg 2010;5:21; http://bit.ly/2BPtzOD.)

The type of trocar you choose is also important. A Scandinavian study in 100 human cadavers found misplacements and organ injuries occurred more frequently using sharp-tipped trocars than blunt ones. Success rates were 92 percent using blunt tips v. 86 percent using sharp-tipped trocars. Neither type of trocar showed a significant decrease in time to complete the procedure. (Scand J Trauma Resusc Emerg Med 2012;20:10; http://bit.ly/2IFXgHO.)

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Watch this informal but informative discussion about trocar insertion with C. Trey Dobson, MD, and Dedrick Luikens, DO.

Pearls

  • The British Thoracic Society released well-researched guidelines in 2010 about chest tube emergencies and insertion skills. (Thorax 2010;65[Suppl 2]; http://bit.ly/2Ua2wET.)
  • The society recommends performing erect, posteroanterior inspiratory chest x-rays for suspected pleural effusion and to confirm tube placement. If identification is difficult, increase specificity by adding supine or lateral decubitus x-rays, ultrasound, and finally CT (in that order) to aid in diagnosis. Ultrasound is an emerging technology for assessing tube placement, but chest x-ray is standard of care. (Medscape. "Tube Thoracostomy." Nov. 16, 2018; http://bit.ly/2IGtiU9.)
  • Ultrasound does, however, detect pleural fluid septations with greater sensitivity than CT, and it can be useful during procedures to reduce the risk of organ puncture, according to the British Thoracic Society guidelines.
  • Keep in mind the potential toxicity of lidocaine for localized injection. The maximum dose is 4-7 mg/kg (0.4 to 0.7 mL/kg), depending on whether epinephrine is used. (UpToDate, "Subcutaneous Infiltration of Local Anesthetics," April 3, 2019; http://bit.ly/2H8AeH1.)
  • Consider less common causes of pleural exudates such as tuberculosis, pulmonary embolism, autoimmune disorders, asbestos, pancreatitis, sarcoidosis, lymphoma, post-MI, and post-CABG. Yellow nail syndrome, drugs, and fungal infection can rarely cause this condition.
  • Malignant effusions can be diagnosed by pleural fluid cytology in about 60 percent of cases, but MRI and PET are the most effective, according to the British Thoracic Society guidelines.
  • Give prophylactic antibiotics when chest tubes are placed in trauma patients, particularly in those with penetrating injury. A meta-analysis of five trials found antibiotics significantly decreased the risk of empyema in patients with blunt or penetrating thoracic trauma compared with placebo. (UpToDate, "Placement and management of thoracostomy tubes and catheters in adults and children," Feb. 19, 2019; http://bit.ly/2GNrHdo.)
  • All kinds of things can go wrong. Read about them in the International Journal of Critical Illness & Injury Science (2014;4[2]:143): http://bit.ly/2T3i1BP.