Tube Thoracostomy: Supplement to NEJM Video - PowerPoint PPT Presentation

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Tube Thoracostomy: Supplement to NEJM Video

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Chest tube of appropriate size. Tube Thoracostomy Tray or ED Trauma Combo Tray ... Connect drainage system to suction. ChuxTM under/around tube ... – PowerPoint PPT presentation

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Title: Tube Thoracostomy: Supplement to NEJM Video


1
Tube ThoracostomySupplement to NEJM Video
2
Credentialing Process at SBUH
  • Watch the video and the supplement
  • 20 min
  • Post test
  • Less than 10 min
  • 80 to pass
  • In Simulation Center
  • Drape/prep station
  • Insertion station (s)
  • Removal station
  • Post Insertion CXR Review
  • Complete 4 supervised procedures

3
Supervised Procedures
  • Supervisor must be credentialed in the procedure
  • That person must observe, critique and correct
    any mistakes
  • If key elements of the process are missed or
    require assistance, you will not be signed off on
    the procedure

4
Tube Thoracostomy
  • 300 CT placed at SBUH per year
  • Complications have included improperly placed
    and improperly positioned tubes, solid organ
    injury, skin infection, empyema, recurrent PTX,
    and failure to drain hemothorax
  • This program is intended to standardize the
    insertion of Chest Tubes and reduce complications

5
Pre Insertion
  • Communication
  • Discuss with Attending the contemplated procedure
    and technique
  • Inform the nursing staff
  • If you are not credentialed, the nurse will stop
    you
  • Consent
  • Required for all procedures
  • Emergency Consent is for true emergencies only
  • Equipment
  • PleurevacTM (will need H2O to fill chambers)
  • Suction
  • Chest tube of appropriate size
  • Tube Thoracostomy Tray or ED Trauma Combo Tray
  • Suture, blade, LidocaineTM, , syringes and
    needles, Vaseline gauze, 2 inch tape, gauze,
    sterile gown/ gloves/ drapes

6
Tube Selection
  • Disease process determines tube size
  • Chest tubes
  • 28F or larger to drain blood
  • In children, tube should be diameter of little
    finger
  • Pigtail Catheters
  • Patient comfort
  • Used for large pneumothorax, or simple effusions
  • Contraindicated in Trauma
  • Contraindicated for hemothorax
  • When a loculated collection is suspected consider
    pigtail placement under ultrasound or CT
    guidance.

7
Photo
  • Photo of a chest tube
  • Photo of a tray of instruments
  • Photo of sterile garb

Will bring an ED combo tray to the photo shoot
8
Insertion of CT
  • It may be necessary to move breast tissue out of
    the site of insertion to avoid injury to the
    breast tissue. Use the inframammary crease or
    fold as a guide for insertion.

Photo of this
9
Insertion of Pigtail or CT
  • Universal Protocol (Time Out) to confirm patient,
    procedure site and side
  • Hand washing
  • Sterile technique is required
  • Hat, mask, sterile gown, gloves and drapes,
  • (unless the patient is in extremis)
  • Local anesthesia (unless the patient is in
    extremis)
  • Always through a new skin incision
  • Secure with suture
  • Do not tape over nipple

10
Pigtail Catheters
  • Advanced needle cephalad over the top of the rib
    at a 60 degrees angle
  • Stop advancing the needle when the pleural space
    is identified by the aspiration of air or fluid
    into the syringe
  • Insert the guide wire into the pleural space
    through the needle

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
11
  • The needle is removed while stabilizing the guide
    wire
  • A small incision is made in the skin
  • Pass the dilator over the guide wire
  • Remove the dilator

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
12
  • Thread the catheter over the guide wire
  • Remove the guide wire
  • Secure the catheter to the skin

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
13
Post Insertion of Pigtail or CT
  • Assessment
  • Assess patient by auscultating lung fields
  • Tape connection to drainage system and ensure
    functioning
  • Place patient on supplemental O2
  • Documentation
  • Procedure Note or Trauma Critical Care Preprinted
    Note must be completed
  • Order and interpret post insertion CXR
  • Document review of CXR in the chart
  • Complete credentialing card

14
Obtain a Post Insertion CXR
15
Removal
  • Patient verification, site verification
  • Hand washing
  • Preparation
  • Connect drainage system to suction
  • ChuxTM under/around tube
  • Prepare occulsive dressing taped on 3 sides
  • Patient instruction/education
  • Three deep breaths and hold
  • Removal
  • Pull at peak inspiration
  • Pull fast, pull completely, simultaneously
    placing dressing
  • Helpful to have an assistant
  • Post removal CXR
  • Order it, review it, document the results in the
    chart

16
Simulation suggestions
  • Some things are hard to simulate
  • Over talk. Say out loud everything that you
    would do in a real situation.
  • Assume nothing

17
Once again, the process
  • Watch the video and the supplement
  • 20 min you are done with this now!
  • Post test
  • On-line
  • In Simulation Center
  • Drape/prep station
  • Insertion station
  • Pigtail insertion
  • Removal
  • CXR interpretation
  • Complete 4 supervised procedures
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