Pre-Hospital Chest Tubes/Thoracostomy

[FLMedic311]

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]

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]

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]

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.

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[StCEMT]

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]

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]

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]

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

 

[CANMAN]

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]

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]

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]

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]

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]

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.


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[STXmedic]

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.


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

 

[Handsome Robb]

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.


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[STXmedic]

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

We've got pericardiocentesis though.


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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]

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.


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[nater]

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

Oh and some betadine.


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

 

[STXmedic]

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

Oh and some betadine.


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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.