Chest tubes were once a bedrock procedure for EM, Resuscitation, and Critical Care. They are now not quite dinosaurs, but they are becoming increasingly unnecessary. In this two-part series on chest tubes, I will discuss EVERYTHING you might ever want to know. In Part 1, I discuss everything surrounind the procedure itself. Part 2 will be just on actual insertion
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thank you, Scott.
that was excellent. clear, concise, very helpful. I’m not in a trauma center, so a refresher (and I am embarrassed to say some of this is new info) was exceedingly welcome.
very cool.
tom fiero, merced, ca
Dear Scott and Emcrit community, how far do you tend to put your drain in?
that is part 2!!! : )
Quick question, since we consider that chest tube placement of both traumatic and spontaneous ptx as probably not necessary, should we not be concerned if we cause a ptx while placing a landmark subclavian line in a stable person?
well that is a multi-level extrapolation
we know we don;t need anything in spont
we know a pigtail is ok for traumatic PTX (which is what iatrogenic is)
we prob. think small traumatic are ok to observe, but the studies aren’t great yet
Hi Nikolai, One concern in this setting is that you have sometimes gone under the first rib into the subclavian and this is why a pneumothorax has occurred. Even a fairly small pneumothorax can cause the line to be pulled out of the vein and drop into the pleural space, which won’t be detected clinically until you are wondering why the patient isn’t responding to their propofol or pressors….. If it was an accidental brush past the lung before striking the subclavian then the risk of this occurring is less, my take on whether or not an intervention required depends… Read more »
Hi Scott, Great podcast and summary of the procedure, some thoughts on indications, technique and a question (partially addressed in part 2) On indication: this technique is also of value when the site of desired insertion has no fluid/air to target using seldinger technique eg. 1. When using ICCs to aggressively warm an arrested hypothermic patient (if like me you have no access to ECMO on site) 2. When the skin over the ideal insertion site is infected/severely scarred preventing dilation eg trying to drain non infected effusion with cellulitis of chest wall Both indications clearly rare, but having experience… Read more »
Saw you answered by bougie question in comments on part 2
the 20 F CT 70 year old, feel 3 days ago, on Eliquis for recent PE, hypercapnic resp failure PaCO2 130, cxr left sided “white out” POCUS fluid, 4.5 L drained with 8F thoracentesis, resp status improved. small ptx (1cm from thoracic wall to lung only at base maybe 8cm in height, then decompensated repeat cxr with some reaccumlation of fluid and prob bigger ptx (not sure if ptx from procedure vs fall) sats dropping figured if fluid drained from 8 french 20 french would be fine – clotted and stopped draining in 15 min decided to replace with 28F… Read more »
probably would have tried flushing before replacing