Pre-Hospital Chest Tubes/Thoracostomy

[FLMedic311]

@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]

@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]

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]

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

 

[VFlutter]

My guess is somewhere with Air Methods ha

 

[8jimi8]

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]

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

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]

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]

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".

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]

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]

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]

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]

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]

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.

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.

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.

. 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]

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.

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]

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

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]

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.

Massive hemothorax is initially managed by the simultaneous restoration of blood volume and decompression of the chest cavity. Large-caliber intravenous lines and rapid crystalloid infusion are begun and type-specific blood is administered as soon as possible. If an auto-transfusion device is available, it may be used. A single chest tube (#38 French) is inserted at the nipple level, anterior to the midaxillary line, and rapid restoration of volume continues as decompression of the chest cavity is completed. When massive hemothorax is suspected, prepare for autotransfusion. If 1500 mL is immediately evacuated, it is highly likely that the patient will require an early thoracotomy.

Some patients who have an initial volume output of less than 1500 mL, but continue to bleed, may require a thoracotomy. This decision is based on the rate of continuing blood loss (200 mL/hour). During patient resuscitation, the volume of blood initially drained from the chest tube and the rate of continuing blood loss must be factored into the amount of intravenous fluid replacement. The color of the blood (arterial or venous) is a poor indicator of the necessity for thoracotomy.

 

[bakertaylor28]

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]

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.



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.



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.



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?

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.