Tube Thoracostomy: Supplement to NEJM Video

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Tube ThoracostomySupplement to NEJM Video
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Credentialing Process at SBUH

• Watch the video and the supplement
• 20 min
• Post test
• Less than 10 min
• 80 to pass
• In Simulation Center
• Drape/prep station
• Insertion station (s)
• Removal station
• Post Insertion CXR Review
• Complete 4 supervised procedures

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Supervised Procedures

• Supervisor must be credentialed in the procedure
• That person must observe, critique and correct
  any mistakes
• If key elements of the process are missed or
  require assistance, you will not be signed off on
  the procedure

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Tube Thoracostomy

• 300 CT placed at SBUH per year
• Complications have included improperly placed
  and improperly positioned tubes, solid organ
  injury, skin infection, empyema, recurrent PTX,
  and failure to drain hemothorax
• This program is intended to standardize the
  insertion of Chest Tubes and reduce complications

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Pre Insertion

• Communication
• Discuss with Attending the contemplated procedure
  and technique
• Inform the nursing staff
• If you are not credentialed, the nurse will stop
  you
• Consent
• Required for all procedures
• Emergency Consent is for true emergencies only
• Equipment
• PleurevacTM (will need H2O to fill chambers)
• Suction
• Chest tube of appropriate size
• Tube Thoracostomy Tray or ED Trauma Combo Tray
• Suture, blade, LidocaineTM, , syringes and
  needles, Vaseline gauze, 2 inch tape, gauze,
  sterile gown/ gloves/ drapes

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Tube Selection

• Disease process determines tube size
• Chest tubes
• 28F or larger to drain blood
• In children, tube should be diameter of little
  finger
• Pigtail Catheters
• Patient comfort
• Used for large pneumothorax, or simple effusions
• Contraindicated in Trauma
• Contraindicated for hemothorax
• When a loculated collection is suspected consider
  pigtail placement under ultrasound or CT
  guidance.

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Photo

• Photo of a chest tube
• Photo of a tray of instruments
• Photo of sterile garb

Will bring an ED combo tray to the photo shoot
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Insertion of CT

• It may be necessary to move breast tissue out of
  the site of insertion to avoid injury to the
  breast tissue. Use the inframammary crease or
  fold as a guide for insertion.

Photo of this
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Insertion of Pigtail or CT

• Universal Protocol (Time Out) to confirm patient,
  procedure site and side
• Hand washing
• Sterile technique is required
• Hat, mask, sterile gown, gloves and drapes,
• (unless the patient is in extremis)
• Local anesthesia (unless the patient is in
  extremis)
• Always through a new skin incision
• Secure with suture
• Do not tape over nipple

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Pigtail Catheters

• Advanced needle cephalad over the top of the rib
  at a 60 degrees angle
• Stop advancing the needle when the pleural space
  is identified by the aspiration of air or fluid
  into the syringe
• Insert the guide wire into the pleural space
  through the needle

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
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• The needle is removed while stabilizing the guide
  wire
• A small incision is made in the skin
• Pass the dilator over the guide wire
• Remove the dilator

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
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• Thread the catheter over the guide wire
• Remove the guide wire
• Secure the catheter to the skin

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
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Post Insertion of Pigtail or CT

• Assessment
• Assess patient by auscultating lung fields
• Tape connection to drainage system and ensure
  functioning
• Place patient on supplemental O2
• Documentation
• Procedure Note or Trauma Critical Care Preprinted
  Note must be completed
• Order and interpret post insertion CXR
• Document review of CXR in the chart
• Complete credentialing card

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Obtain a Post Insertion CXR
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Removal

• Patient verification, site verification
• Hand washing
• Preparation
• Connect drainage system to suction
• ChuxTM under/around tube
• Prepare occulsive dressing taped on 3 sides
• Patient instruction/education
• Three deep breaths and hold
• Removal
• Pull at peak inspiration
• Pull fast, pull completely, simultaneously
  placing dressing
• Helpful to have an assistant
• Post removal CXR
• Order it, review it, document the results in the
  chart

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Simulation suggestions

• Some things are hard to simulate
• Over talk. Say out loud everything that you
  would do in a real situation.
• Assume nothing

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Once again, the process

• Watch the video and the supplement
• 20 min you are done with this now!
• Post test
• On-line
• In Simulation Center
• Drape/prep station
• Insertion station
• Pigtail insertion
• Removal
• CXR interpretation
• Complete 4 supervised procedures