Chest tubes
One of my favorite emergency room procedures is placement of a chest tube. The past week I've placed a number of them for developing tension pneumothoraces. Though I enjoy doing them now, I was petrified of learning the procedure as an intern.
Its a pretty straight-forward procedure that interupts a process that would result in the patient's death. The typical scenario is a patient who has been in a car wreck and has had significant force applied to their chest. Usually they have a number of broken ribs on that side in addition to the collapsed lung (pneumothorax).
A pneumothorax kills you fairly quickly if left untreated. You're lung is basically a big balloon comprised of a number of smaller balloons (alveoli). With blunt chest trauma, the lung is either punctured by broken ribs, or simply has a section that pops due to the rapid application of force after hitting the steering wheel or something. With each breath, air escapes out of the lung into the space between the lung and the thoracic wall. Each breath therefore collapses the lung just a little bit more. Eventually, so much air has escaped into the thorax that the lung is entirely collapsed.
What is lethal about a pneumothorax, though, isn't the collapsed lung. I have had several patients in whom we removed an entire lung for cancer, and they did just fine with one lung. Patients with a pneumothorax die because eventually the amount of air that has escaped into the pleural space is so great that it actually pushes the heart and veins that drain into it (superior and inferior vena cava) way over to the other side of the chest. Eventually things are pushed over so far that the veins are kinked to the degree that blood cannot return to the heart from the rest of the body. Your heart then has no blood to pump anywhere, and you die.
All this is stopped by making a several centimeter incision on the skin, dividing the underlying intercostal muscles between the ribs, and then putting a tube into the space between the lung and the chest wall. The air all comes rushing out, no veins get kinked, and another trauma patient is saved to eventually be released back into the wild.
Its a procedure short on technical skills (though you can actually kill someone during chest tube placement by doing something stupid like putting the tube into the heart) and high on immediate gratification.
Its a pretty straight-forward procedure that interupts a process that would result in the patient's death. The typical scenario is a patient who has been in a car wreck and has had significant force applied to their chest. Usually they have a number of broken ribs on that side in addition to the collapsed lung (pneumothorax).
A pneumothorax kills you fairly quickly if left untreated. You're lung is basically a big balloon comprised of a number of smaller balloons (alveoli). With blunt chest trauma, the lung is either punctured by broken ribs, or simply has a section that pops due to the rapid application of force after hitting the steering wheel or something. With each breath, air escapes out of the lung into the space between the lung and the thoracic wall. Each breath therefore collapses the lung just a little bit more. Eventually, so much air has escaped into the thorax that the lung is entirely collapsed.
What is lethal about a pneumothorax, though, isn't the collapsed lung. I have had several patients in whom we removed an entire lung for cancer, and they did just fine with one lung. Patients with a pneumothorax die because eventually the amount of air that has escaped into the pleural space is so great that it actually pushes the heart and veins that drain into it (superior and inferior vena cava) way over to the other side of the chest. Eventually things are pushed over so far that the veins are kinked to the degree that blood cannot return to the heart from the rest of the body. Your heart then has no blood to pump anywhere, and you die.
All this is stopped by making a several centimeter incision on the skin, dividing the underlying intercostal muscles between the ribs, and then putting a tube into the space between the lung and the chest wall. The air all comes rushing out, no veins get kinked, and another trauma patient is saved to eventually be released back into the wild.
Its a procedure short on technical skills (though you can actually kill someone during chest tube placement by doing something stupid like putting the tube into the heart) and high on immediate gratification.
posted by The Mad Hatter at 12:37 PM
6 Comments:
oh my goodness hans. and the highlight of my day is ordering a tub transfer bench for someone. which is probably fortunate as i would probably be flat on the floor in a minute with your job. at least i can say i have a brother who does what you do. . .
What do you guys do if a paramedic already got the chance to decompress the chest with a needle before the patient arrives at your facility? Do you leave that in place and use it, or replace it with a chest tube anyway?
Gerald, in that case we still put a chest tube in. Usually the needle decompression won't entirely evacuate the pneumothorax, and the patient probably will need to have a chest tube in place and on suction for a while before the lung seals back up.
I feel kind of gyped cause I've actually never seen this procedure. Our ER is quite small, and all of the good traumas get airlifted or transported by ground to the trauma center in Greenville.
In regard to your comment: I may occasionally look or smell like road kill, but I can assure you that up to this point vehicles have successfully avoided me.
I hear Carlos be staying with you a few days every other week. You’ll have to zoom over for a visit again sometime.
That makes sense, I guess you wouldn't really be able to suction too well through a needle catheter. For the first time now I saw a patient with a chest tube hooked up to suction. Wish I could have watched it being placed. What do you do to seal up the hole that is left when the chest tube is removed? Sorry so many questions...
Hey Gerald, sorry this took so long. There are two techniques for dealing with the hole after the chest tube is pulled. Some people place the suture securing the chest tube in such a way that it can be tied after tube removal creating a tissue seal over the hole. The other method, which we usually use on trauma, is to use an occlusive dressing to cover the hole until the body has time to close it up. This is less painful to the patient, but probably leaves a worse scar.
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