# Pre-Hospital Chest Tubes/Thoracostomy



## FLMedic311 (Dec 3, 2016)

Just curious who out there are doing field chest tubes or finger thoracotomy and what your indications/protocols are for the procedure?  What are your thoughts on them and or any Pearls you would like to share?  Thanks again!


----------



## VentMonkey (Dec 3, 2016)

FLMedic311 said:


> Just curious who out there are doing field chest tubes or finger thoracotomy and what your indications/protocols are for the procedure?  What are your thoughts on them?


We have neither at our current service. Given our average time we typically spend on "scene calls" in patients requiring chest decompression in relation to the average ETA to our regional trauma center, I personally do not feel we need a chest tube protocol.

If I personally had a choice between the two, I would venture to guess finger thoracotomy would be more fitting as this is much more of an "emergent procedure" similar to the same sense of urgency seen with surgical cricothyrotomy. These seem more of a "nice to have" skillset/ protocol as chest decompression seems to be working well enough for our service.


----------



## VFlutter (Dec 3, 2016)

We are trained to insert chest tubes however our protocols only allow us to "assist" a MD in the procedure. Having said that if the ER Doctor refuses or is unable to place one we will take over and do it. I wish we had finger thoracotomy in our protocols for certain situations but I do think medical control would allow it.


----------



## TransportJockey (Dec 3, 2016)

When I worked in west Texas we were trained and credentialed to place chest tubes on our ground 911 units and our fixed wing medevacs. Did a few there due to sheer distance from anyone and prolonged ETA of air resources. 

Sent from my SM-N920P using Tapatalk


----------



## StCEMT (Dec 3, 2016)

Just dropping this to see what happens here, listened to a few emcrit podcasts on my fight about this. Curiosities. 

Will say though, I agree with Vent, seems like something that'd be more under the nice to have. The people who would actually need this I could probably manage without those options until I get to a hospital, which is not very long at all depending where I am.


----------



## CANMAN (Dec 6, 2016)

I would argue that if your program is doing either then you should also be carrying blood products on the A/C. 

I just recently changed programs, went from one who was very evidence based and had PRBC's for every mission, to one which is a little behind the times protocol wise and doesn't have blood. The blood was clearly not a factor in my decision but I wouldn't want to drop a chest tube and not have the ability to replace blood out with anything other than blood. I am also in a relatively urbanized area, with most flights averaging less than 30 minutes to a tertiary trauma center.


----------



## FLMedic311 (Dec 7, 2016)

CANMAN said:


> I would argue that if your program is doing either then you should also be carrying blood products on the A/C.
> 
> I just recently changed programs, went from one who was very evidence based and had PRBC's for every mission, to one which is a little behind the times protocol wise and doesn't have blood. The blood was clearly not a factor in my decision but I wouldn't want to drop a chest tube and not have the ability to replace blood out with anything other than blood. I am also in a relatively urbanized area, with most flights averaging less than 30 minutes to a tertiary trauma center.



Just curious did you guys have means to warm your blood prior to or during infusion?


----------



## FLMedic311 (Dec 7, 2016)

Hey guys!  Still looking for any procedure/protocols that anyone may have in place if they could share that!  Thanks again!


----------



## CANMAN (Dec 8, 2016)

FLMedic311 said:


> Just curious did you guys have means to warm your blood prior to or during infusion?



Unfortunately, not really. Which amongst other reasons, is why my current program doesn't want to make the trek to obtain and start to carry blood. I would be curious as to what other programs do in this setting. We know that hypothermia doesn't help us with coagulation in our hypovolemic trauma patients, but yet we are required to carry blood at 4C and then rapidly infuse it into our trauma patient when needed. We had providers that would put it on a pressure bag then insert it into our fluid warmer, or place two chemical hot packs around it, but I doubt that was really warming the blood much prior to making it to patient. 

There were definitely calls like GI bleeds, esophageal varices, aortic emergencies etc where having the blood was handy vs. trying to get it from Our Lady of Perpetual Hope Medical Center, but the storage for multiple missions vs. inability to rewarm it quickly is certainly something to consider.


----------



## nater (Jan 28, 2017)

Bumping an old one, I know...

We are allowed to place chest tubes in the field. The Turkel devices have been successful cut down on our need for a chest tube in the field, but we still keep them and use them when necessary. Indications are pretty standard for suspected tension pneumothorax.

On the blood comment, we also carry 2 units of RBCs and FFP. They get run through an EnFlow fluid warmer and we keep patients warm with a foil transport cocoon and warming pads if needed. The EnFlow seems to work well to reach a target temperature of 40c.


----------



## TXmed (Jan 28, 2017)

We use the thermal angels, we will also use warmed fluids while giving the blood also. We have had lengthy discussions with our education department and the thought is that us administering 2 units of PRBC's <40c isnt gonna make them hypothermic, its the combination of everything and should focus on that rather then the JUST the temp of the fluid.

We dont do chest tubes, which doesnt bother me. But i do wish we could do finger thoracotamy's , from my understanding theyre showing to be safer than the darts.


----------



## VentMonkey (Jan 28, 2017)

TXmed said:


> We dont do chest tubes, which doesnt bother me. But i do wish we could do finger thoracotamy's , from my understanding theyre showing to be safer than the darts.


Neither do we, and I agree with this post. I would think given the success shown, the fact that hardly anything done in the field is a "sterile procedure" in the first place, and the fact that finger thoracotomy's seem more fitting for the "emergent" type procedure, it is a no brainer that they begin to replace in-field chest tubes for the majority of services in general, let alone needle decompression in the face of a hemodynamically unstable pneumo. With the advent of, and popularity gained behind prehospital thoracotomy, the other procedures seem antiquated to say the least.


----------



## STXmedic (Jan 28, 2017)

We're doing finger thoracostomies down here (South Texas). No chest tubes. Standing orders with traumatic arrest or high suspicion of tension pneumothorax.

The only pearl, which you probably already know, is watch out for ribs on blunt trauma to the chest. They're f'ing sharp and big exposure hazards.


----------



## Handsome Robb (Jan 28, 2017)

Our Tac team just got finger thoracostomies approved. I'm assuming we'll have them in the next year or so for regular ground units. 

Same indications as @STXmedic. 


Sent from my iPhone using Tapatalk


----------



## STXmedic (Jan 28, 2017)

Handsome Robb said:


> Our Tac team just got finger thoracostomies approved. I'm assuming we'll have them in the next year or so for regular ground units.
> 
> Same indications as @STXmedic.
> 
> ...


Dang, our field medics beat y'all to something?! I guess there's a first for everything...


----------



## Handsome Robb (Jan 28, 2017)

STXmedic said:


> Dang, our field medics beat y'all to something?! I guess there's a first for everything...



Apparently. Y'all have POCUS too don't you? We haven't gotten it yet. 

We've got pericardiocentesis though. 


Sent from my iPhone using Tapatalk


----------



## STXmedic (Jan 28, 2017)

Handsome Robb said:


> Apparently. Y'all have POCUS too don't you? We haven't gotten it yet.
> 
> We've got pericardiocentesis though.
> 
> ...


We only have POCUS on our SOU units (two units out of 39 or 40). We're supposed to have pericardiocentesis too (SOU), but they apparently haven't ordered the equipment yet (in over a year... gotta love city purchasing.)


----------



## Handsome Robb (Jan 28, 2017)

STXmedic said:


> We only have POCUS on our SOU units (two units out of 39 or 40). We're supposed to have pericardiocentesis too (SOU), but they apparently haven't ordered the equipment yet (in over a year... gotta love city purchasing.)



Ours isn't anything fancy. Just a 5" 14g catheter and 20cc syringe. 

Oh and some betadine. 


Sent from my iPhone using Tapatalk


----------



## nater (Jan 28, 2017)

Handsome Robb said:


> Ours isn't anything fancy. Just a 5" 14g catheter and 20cc syringe.
> 
> Oh and some betadine.
> 
> ...



Same here, we keep the 5" catheters on hand just in case, but don't use anything else special.


----------



## STXmedic (Jan 28, 2017)

Handsome Robb said:


> Ours isn't anything fancy. Just a 5" 14g catheter and 20cc syringe.
> 
> Oh and some betadine.
> 
> ...


That's exactly what we're waiting on (might be 8"). But since it's a new piece of equipment, it has to apparently go through a whole bunch of channels in city budgeting. And since it's only for two units, it's low on their priority list. Same thing for gigli saws.


----------



## FLMedic311 (Jan 29, 2017)

@STXmedic regarding your thoracostomies, what has been the amount of exposures due to rib Fx, and for that matter the prevalence of procedure complications?


----------



## STXmedic (Jan 29, 2017)

FLMedic311 said:


> @STXmedic regarding your thoracostomies, what has been the amount of exposures due to rib Fx, and for that matter the prevalence of procedure complications?


We've been lucky in having none of those exposures yet. Our docs have also all told us that if we think there's a high likelihood for severely fractured ribs at the incision site, to just go with an anterior axillary decompression instead.

No complications yet that I'm aware of (we've only been doing it for about a year). We had one confirmed save within the first week of implementing the procedure. I'm not sure how many have been successful since, but I haven't heard of any major complications.


----------



## 8jimi8 (Apr 26, 2017)

FLMedic311 said:


> Just curious who out there are doing field chest tubes or finger thoracotomy and what your indications/protocols are for the procedure?  What are your thoughts on them and or any Pearls you would like to share?  Thanks again!


----------



## STXmedic (Apr 26, 2017)

Holy ****, @8jimi8 is back?? Where are you at nowadays?


----------



## VFlutter (Apr 26, 2017)

My guess is somewhere with Air Methods ha


----------



## 8jimi8 (Apr 26, 2017)

STXmedic said:


> Holy ****, @8jimi8 is back?? Where are you at nowadays?


No longer with AMC. Im with a family owned company. Our rotor program is just about ready to launch.


----------



## 8jimi8 (May 5, 2017)

While i understand the logic of replacing blood. Whether or not you carry it, it isn't like blood pooling in their chest is part of their circulating volume. It it just because now you can quantify it that it bother you?  Replace blood with fluid 3:1



CANMAN said:


> I would argue that if your program is doing either then you should also be carrying blood products on the A/C.
> 
> I just recently changed programs, went from one who was very evidence based and had PRBC's for every mission, to one which is a little behind the times protocol wise and doesn't have blood. The blood was clearly not a factor in my decision but I wouldn't want to drop a chest tube and not have the ability to replace blood out with anything other than blood. I am also in a relatively urbanized area, with most flights averaging less than 30 minutes to a tertiary trauma center.


----------



## CANMAN (May 12, 2017)

8jimi8 said:


> While i understand the logic of replacing blood. Whether or not you carry it, it isn't like blood pooling in their chest is part of their circulating volume. It it just because now you can quantify it that it bother you?  Replace blood with fluid 3:1



Poorly worded post on my part. Mainly saying that if you have tube thoracostomy in your toolbox then you're working in an aggressive program and you should also be carrying blood products. Replacing blood with fluid I think will eventually go away all together and we all know is no substitute for the actively bleeding patient.


----------



## Carlos Danger (May 13, 2017)

8jimi8 said:


> While i understand the logic of replacing blood. Whether or not you carry it, it isn't like blood pooling in their chest is part of their circulating volume. *It it just because now you can quantify it that it bother you?  *


No, what is bothersome isn't the fact that you can quantify the blood loss after draining a hemothorax, it's the rapid exsanguination that can occur once you release the tamponade caused by a huge thoracic hematoma.

Most hemothoraces are due to injury to the intercostal vessels and small pleural vessels and are self limiting (they clot and stop bleeding on their own). Draining them releases pressure on the great vessels and improves hemodynamics, and does not cause any significant additional blood loss. But in a massive hemothorax resulting from injury to the great vessels or the brachiocephalic vasculature, a patient can lose almost half their blood volume into their thoracic cavity. And (especially in an anticoagulated patient) the pressure caused by that hematoma can be the only thing keeping the other half of their blood volume in circulation and out of the thoracic cavity.

I suppose one can make the argument that these patients are usually practically dead (if not actually dead) before we drain their chest, so we aren't really making them worse by draining their hemothorax. But this is why you hear people say "if you are going to be placing chest tubes, you really should have blood available".
*
*


8jimi8 said:


> Replace blood with fluid 3:1



And this is the other concern with not having blood available when managing thoracic trauma. Replacing large volumes of lost blood with even larger volumes of crystalloid is known to be really bad for patients.


----------



## TXmed (Jun 27, 2017)

For those of you that are able to perform prehospital chest tubes, do you still secure it via sutures ? Or some other fancy way ?


----------



## nater (Jun 28, 2017)

We do not suture them in. To secure we use 2 sterile towel clamps, one over and one under the tube, both just into the skin. Both clamps and the tube are taped together to hold the tube until we arrive and the docs can suture it in.


----------



## SpecialK (Jun 28, 2017)

Yes, finger thoracostomy in addition to needle decompression for all ICPs.  HEMS have a little tie in chest tube thing I've seen, I have no idea what it is though, but I've seen it in London as well.  The QAS use some adapted version of an ET tube.


----------



## SandpitMedic (Jul 4, 2017)

nater said:


> We do not suture them in. To secure we use 2 sterile towel clamps, one over and one under the tube, both just into the skin. Both clamps and the tube are taped together to hold the tube until we arrive and the docs can suture it in.


Or replace it...


----------



## CWATT (Jul 31, 2017)

StCEMT said:


> I agree with Vent, seems like something that'd be more under the nice to have.



If you take the John Hinds approach, every traumatic arrest would involve a finger thorascostomy to relieve and/or rule-out  pneumothorax and detect hemmothorax.  It is a primary element of that protocol. 



CANMAN said:


> I would argue that if your program is doing either then you should also be carrying blood products on the A/C.



Detecting and relieving a hemothorax and reprofusing lost fluid are two separate entities.  Would blood products help the situation, absolutely, but a finger thoracostomy is not dependent on blood products on-hand. 



CANMAN said:


> I wouldn't want to drop a chest tube and not have the ability to replace blood out with anything other than blood.



Any blood in the thorasic cavity has already third-spaced / is no longer participating in the circulatory system, so draining it will only benefit the patient.



Remi said:


> . But in a massive hemothorax resulting from injury to the great vessels or the brachiocephalic vasculature, a patient can lose almost half their blood volume into their thoracic cavity. And (especially in an anticoagulated patient) the pressure caused by that hematoma can be the only thing keeping the other half of their blood volume in circulation and out of the thoracic cavity.



Hrm...  is this evidence based?  I feel like the effect of a massive hemothorax on hemodynamics and oxygenation/ventilation would outweigh any possible tamponade of bleeding.  ...but I've been wrong before.  Do you have any references where I can read-up on this?


----------



## Carlos Danger (Aug 1, 2017)

CWATT said:


> Any blood in the thorasic cavity has already third-spaced / is no longer participating in the circulatory system, so draining it will only benefit the patient.



Untrue. I explained how draining it can potentially harm a patient.




CWATT said:


> Hrm...  is this evidence based?  I feel like the effect of a massive hemothorax on hemodynamics and oxygenation/ventilation would outweigh any possible tamponade of bleeding.  ...but I've been wrong before.  Do you have any references where I can read-up on this?



Is what evidence based? The fact that a massive hemothorax can cause exsanguination?

The effects of a massive hemothorax on ventilation and hemodynamics can be fatal, of course. With that in mind, I don't think anyone is suggesting that a hemodynamically significant pneumothorax or hemothorax shouldn't be treated. What some are saying is that ideally, blood should be available when you treat it.

It is one thing to say "you shouldn't do this" and quite another to say "if you are going to do this, you really should have these other tools available because they might be needed".


----------



## CWATT (Aug 1, 2017)

Remi said:


> Is what evidence based? The fact that a massive hemothorax can cause exsanguination?






Remi said:


> the pressure caused by that hematoma can be the only thing keeping the other half of their blood volume in circulation and out of the thoracic cavity.



I just want to make sure I understand you correctly.  It sounds that are you saying a complete unilateral thorasic hematoma would be self-tamponading and life-sustaining despite the loss of approx. 50% of the circulating volume.

Do I understand you correctly?  If so, I'm asking if this is evidence based or speculation, and whether you can link me to an article that discusses this.


----------



## Carlos Danger (Aug 2, 2017)

CWATT said:


> I just want to make sure I understand you correctly.  It sounds that are you saying a complete unilateral thorasic hematoma would be self-tamponading and life-sustaining despite the loss of approx. 50% of the circulating volume.
> 
> Do I understand you correctly?  If so, I'm asking if this is evidence based or speculation, and whether you can link me to an article that discusses this.



Pretty much every resource that discusses thoracic trauma covers this. 

Fewer than 10% of hemothoraces are massive hemothoraces (>1500ml initial blood loss). A relatively small percentage of massive hemothoraces present with ongoing bleeding and decompensate the way I am describing. But it does happen - you will see it if you spend any significant amount of time with a busy trauma service.

What follows is an excerpt from ATLS. This is where the recommendation for blood availability when managing thoracic trauma comes from:



> D. Massive Hemothorax
> 
> Massive hemothorax results from a rapid accumulation of more than 1500 mL of blood in the chest cavity. It is most commonly caused by a penetrating wound that disrupts the systemic or hilar vessels. It may also be the result of blunt trauma. The blood loss is complicated by hypoxia. The neck veins may be flat secondary to severe hypovolemia or may be distended because of the mechanical effect of intrathoracic blood. This condition is discovered when shock is associated with the absence of breath sounds and/or dullness to percussion on one side of the chest.
> 
> ...


----------



## bakertaylor28 (Aug 3, 2017)

Two rules of government budgeting:

1. They'll do ANYTHING they can to AVOID buying it, no matter how badly it's needed for smooth and efficient work flow, etc.

2. If it's GOOD as compared to other Items of similar nature (Think your diamond grips) They'll drop it faster than terminal velocity.


----------



## CANMAN (Aug 6, 2017)

CWATT said:


> If you take the John Hinds approach, every traumatic arrest would involve a finger thorascostomy to relieve and/or rule-out  pneumothorax and detect hemmothorax.  It is a primary element of that protocol.
> 
> 
> 
> ...



Thanks for the educational tid bits. I don't believe my post said anything about thoracostomy being dependent on blood products, but it's nice to have both, and REMI has already done a fine job in responding to the rest. In any major trauma center if you're dropping a chest tube and have a large amount of blood out, you replace blood because there will be continued bleeding until you get to the O.R. I have seen plenty of patients almost exsanguination in the trauma bay once that pressure is release, and I think REMI has posted the garden hose concept before. Same applies here, just a larger cavity, and IF available thoracostomy and blood in is the preferred method which I believe is what I previously said... We are also keeping these patient's hypotensive until the hemorrhage can be controlled in most situations.


----------

