Clinical Emergency Procedures :CHEST THORACOSTOMY

BYAhmed AL Jabri R3

Mentor : Dr. Nasser AL-Habsi

outlines

• Pathophysiology of Hemo/PTX • INDICATIONS FOR TT • CONTRAINDICATIONS ( If any ? ) • Procedure : • TT in Pediatric Pateints • TT complications/ Pitfalls • Take home SMS .

Pathophysiology

• The pleural space that normally separates the visceral and parietal pluerae has a thin layer of lubricating fluid separating the layers

• small negative pressure in the pleural space keeps the lung inflated

• Inspiration, the negative intrathoracic pressure increases, leading to the expansion of the lung

Pathophysiology

• The addition of blood, fluid, or air in the pleural space disrupts the normal pressure gradient and interferes with normal inspiratory-induced inflation, leading to the “collapse” of the lung

INDICATIONS FOR TT

• PTX• HTX• Empyema

INDICATIONS : PTX

• Spontaneous v.s secondary • Underlying lung disease v.s normal lung status • pt stable v.s unstable . • Large v.s small PTX• Pt is for transport • Mechanism of injuries

Guidelines of the American College of Chest Physicians for the definition of a clinically stable Pateint with PNEUMOTHORAX

• A clinically stable patient must have all of the following present:

1.respiratory rate, <24 breaths/min; 2.heart rate, >60 beats/min or <120 beats/min;3. normal blood pressure, 4.room air O2 saturation, >90%; and

5.can speak in whole sentences between breaths.

Small PTX IN STABLE PT • ALL pt with penetrating thoracic injuries who

will require Transport >> TT is indicated

• Traumatic small PTX in pt who will require PPV can turn to tension PTX >> good consensus that TT is indicated

INDICATIONS : HTX• About three fourths of patients with a traumatic HTX can be

managed by TT and volume replacement alone.

• Indications for thoracotomy after TT :1. Massive hemothorax, >1000–1500 mL initial drainage 2. >200 mL/hr for first 3 or more hr 3. Increasing size of hemothorax on chest film4. Persistent hemothorax after two functioning tubes placed 5. Clotted hemothorax 6. Large air leak preventing effective ventilation 7. Persistent air leak after placement of second tube or inability to

fully expand lung

CONTRAINDICATIONS

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CONTRAINDICATIONS

• For unstable injured patients with a PTX or an HTX, there are no absolute contraindications to a TT

• In the stable patient, relative contraindications include anatomic problems such as the presence of multiple pleural adhesions, emphysematous blebs, or scarring. Coagulopathic patients

Procedure :

1. equipments2. Tube insertion site3. Patient preparation4. Anesthesia 5. Insertion6. Confirmation of tube placement7. Securing the tube . 8. Draining and Suction Systems 9. ? Prophylactic antibiotics

Recommended Equipment for TT

• Procedure • Sterile drapes • 10- to 20-mL syringe and assorted needles (for local anesthesia) • Local anesthetic (1%–2% lidocaine) • Antiseptic solution• No. 10 scalpel • Large clamps (Kelly) • Needle holder• Chest tubes (size appropriate)• No. 0 or 1-0 silk or similar suture• Forceps Straight (suture) scissors • Large, curved (Mayo) scissors • Soft arm restraints

Recommended Equipment for TT• Drainage System and Tubing :• Drainage apparatus with sterile water for water

seal • Hard plastic serrated connectors • Sterile tubing

• Dressing :• Petroleum gauze or similar occlusive dressing • Gauze or similar pads • Adhesive tape

Video

TT in Pediatric Pateints

• TT in pediatric patients is essentially the same as that for adults

• Weight (kg) Chest Tube (Fr) • <3 8–10 • 3–5 10–12 • 6–10 12–16 • 11–15 17–22 • 16–20 22–26 • 21–30 26–32 • >30 32–40

COMPLICATIONS / PITFALLS

Physical Complications of Tube TT• Infection: • Pneumonia ,• Empyema ,• Local incision infection ,• Osteomyelitis, • Necrotizing fasciitis

• Injuries—Bleeding • Local incision hematoma ,• Intercostal artery or vein laceration ,• Internal mammary artery laceration (with midclavicular line placement)• Pulmonary vein or artery injury • Great vessel injury

Physical Complications of Tube TT• Injuries to Solid Organs or Nerves : • Lung, liver, spleen, diaphragm, stomach, colon; long thoracic nerve, intercostal

nerve

• Physiologic :• Allergic reactions to surgical preparation or anesthesia , • Pulmonary atelectasis, • Reexpansion pulmonary edema ,• Reexpansion hypotension

• Miscellaneous • Subcutaneous or mediastinal emphysema • Persistent pneumothorax • Retained hemothorax • Recurrence of pneumothorax after chest tube removal

Mechanical Complications of TT• Mechanical Problems :• Chest tube dislodgment from chest wall • Incorrect tube position • Subcutaneous placement • Intra-abdominal placement

• Air Leaks • Leaks within the drainage system (tubing or drainage device)• Last tube port not within pleural space Leaks from skin site

• Blocked Drainage • Flow of drainage contents into chest from elevation of drainage bottles• Kinked chest tube or drainage tubes • Clots occluding the tube

TAKE HOME MASSEGE

• CLINICAL JUDGEMENT FOR INDICATIONS FOR TT

• YOU NEED TO MASTER IT ( ?? TRUMA TEAM )

• ALWAYS SECURE THEN CONFIRM YOUR TUBE PLACEMENT.

You will remember some of what you hear, much of what you read, more of what you see ,And almost all of what you experience and

((((((((((((((((understand fully

TNX v.s PTX