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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine 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.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It 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.

Monday, April 1, 2019

Trocar during Times of Trauma

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.