Wayne Pneumothorax Tray

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I wanted to do a little blurb about the pigtail kit at Community. I often find that we as providers become pretty comfortable with what we know and uncomfortable with any tools we haven't used before. Back in July, I had to do a chest tube at Community, and the kit was totally different (and rest of the procedure was completely different because of this). This kit is not saldinger technique, and doesn't require use of needles (though you still should use lido obvs). I was initially confused when I was looking at the kit, and so wanted to write this out in case you face the same!


The kit comes with a 14Fr pigtail, trocar, long blade that goes in trocar (looks like a hollow bore needle, but isn't!), 11 blade, tubing, three way stopcock, and one way air valve. The main difference from the pigtail kits that we're used to, is there is no guidewire and no needle! Meaning, you're not going in with the needle first. 


Essentially, you will end up inserting the pigtail with trocar and long blade in one piece, into the incision site. The trocar is placed in a larger fenestrated hole towards the end of the pigtail.


















The steps for the procedure include;

 

  1. Confirm the location, fool (pick the side with the pneumo, and do it in the triangle of safety)

  2. Prep the site with chlorhexadine

  3. Anesthetize the site with lido

  4. Get sterile

  5. Drape and re-prep (you could probably prep once, but I'm a little OCD)

  6. Combine the pigtail, trocar, and long blade as shown in image

  7. Make your incision above the rib with the 11 blade

  8. Taking the combined long blade, in trocar, in pigtail - insert at your incision, aimed towards the lung apex

  9. Remove the long blade once you pass the resistance of the pleura

  10. Advance the trocar and pigtail, before removing the trocar and continuing to advance the pigtail to the desired depth (usually around 15-20 cm)

  11. Suture the pigtail in place and place a dressing over it

  12. Attach the tubing with the one way valve or to a pleurovac



















Now for those of you that may read this and say "omg, I'm not trying to just stab someone," well, you are not alone. Others have commented the same. And if you are so inclined to place this pigtail using saldinger technique, that is still possible. You will need to crack open a central line kit and pillage the needle, syringe, and guidewire. The trocar in the Wayne Pneumothroax tray is hollow bore, and the guidewire can still be fed through that. Hope this was helpful! 

NG Tube for SBO

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Is a nasogastric (NG) tube really needed for management of small bowel obstruction (SBO)? NG tube placement is one of my least favorite ED procedures. I therefore find myself hesitating every time surgery requests one, but what is the evidence behind it?

 

Surprisingly, there is little data and no randomized control trials on the use of NG tubes in SBO. A chart review in 2013 looked at 290 patients admitted with SBO. 20% of those 290 patients had a NG tube placed. They found that ⅔ of these patients were managed non-operatively, irrespective of NG tube placement. In addition, decompression with an NG tube was not found to be associated with decreased bowel ischemia or need for surgery. Use of an NG tube was actually found to be associated with worse outcomes, such as increased length of hospital stay, higher complication rate, and longer time to resolution.

 

Part of the reason that I dislike this procedure is the apparent discomfort we cause when placing them. Patients routinely rate it as one of the most painful procedures performed in the ED. We attempt to decrease pain with anesthetics, even though many ED physicians do not believe them to be effective. A RCT was done assessing the use of surgical lubricant versus topical lidocaine and phenylephrine for the nose with tetracaine and benzocaine spray for the throat. Patients reported a significant decrease in discomfort when providers used vasoconstrictors and topical anesthetics compared to surgical lubricant. 

 

However, there are some cases where NG tubes may be indicated. Patients who are vomiting after antiemetics or have a significantly distended stomach may benefit. Rather than placing them on all patients diagnosed with an SBO, we should select patients for this procedure based on their symptoms.


Thanks for reading!

Ariella 

Resources:

Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? Am Surg. 2013 Apr;79(4):422-8. PMID: 23574854

Paradis M. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 1: Is routine nasogastric decompression indicated in small bowel occlusion? Emerg Med J. 2014 Mar;31(3):248-9. doi: 10.1136/emermed-2014-203617.1. PMID: 24532357

Singer AJ, Konia N. Comparison of topical anesthetics and vasoconstrictors vs lubricants prior to nasogastric intubation: a randomized, controlled trial. Acad Emerg Med. 1999 Mar;6(3):184-90. doi: 10.1111/j.1553-2712.1999.tb00153.x. PMID: 10192668

Witting MD. "You wanna do what?!" Modern indications for nasogastric intubation. J Emerg Med. 2007 Jul;33(1):61-4. doi: 10.1016/j.jemermed.2007.02.017. Epub 2007 May 30. PMID: 17630077

POTD: ECMO

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Hello everyone! Let's talk about ECMO. I was first introduced to ECMO in the era of pre-vaccine COVID, where it was often hailed as the Hail Marry of solutions for severe COVID cases in younger patients. But ECMO can be used for so much more, including a recently discussed topic - hypothermia.

What is ECMO?

ECMO, or extracorporeal membrane oxygenation, is a prolonged cardiopulmonary support technique that allows oxygenation of the blood bypassing the heart and lungs. It differs from cardiopulmonary bypass in that it requires less anticoagulation and allows for longer duration of treatment. 

Who qualifies for ECMO?

Criteria for ECMO include acute severe cardiac or pulmonary failure that is potentially reversible and has failed conventional treatment and carries a high risk of death. Conditions include:

  • ARDS and severe respiratory failure (severe hypercapnia pH < 7.20, or P/F ratio < 70)

  • poor gas exchange/obstruction (massive PE)

  • acute pulmonary injury: smoke inhalation, contusion, drowning

  • nonischemic cariogenic shock, cardiac/pulmonary trauma, massive PE

  • bridge to lung or cardiac transplant or LVAD

Who does not qualify for ECMO?

Absolute contraindications include:

  • unwitnessed cardiac arrest

  • non-reversible, progressive lung or cardiac disease that is not a transplant candidate

  • pulmonary hypertension

  • advanced cancer

  • >120 kg

Relative contraindications include:

  • older than 75 years

  • CPR > 60 minutes

  • CNS injury

  • multi organ failure or trauma

What types of ECMO exist?

VV or veno-venous: the most common access, typically central vein IVC access (femoral, IJ), passes through oxygenator, and deposits in a large vein near RA (IJ, subclavian)

  • provides respiratory support but not circulatory support

  • pathologies: COPD, ARDS, PNA, smoke inhalation injury, status asthmatics, airway obstruction, drowning

VA or veno-arterial: can be peripheral or central, access is central vein, passes through oxygenator, and deposits in arterial access around pulmonary artery

  • provides both respiratory and cardiac support

  • pathologies: non-ischemic cardiogenic shock, heart/lung transplant, LVAD failure, PE, sepsis

Complications:

  • clot formation

  • bleeding

  • vessel trauma, LV distension

  • North-south syndrome - hypoxia and cyanosis in cephalic and lower extremities outside of range of circuit access

https://wikem.org/wiki/Extracorporeal_membrane_oxygenation

https://www.emra.org/emresident/article/ecmo-in-the-ed/