Wayne Pneumothorax Tray

 ·   · 

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! 

Use (or lack thereof) of speculum exams in the ED

 ·   · 

Today I want to talk about the use of speculum exams in the emergency department. A recent post on Life in the Fastlane discussed this topic and questioned whether there is much valuable information to be gained, and whether that warrants doing an invasive procedure. The post laid out a stringent set of presentations that definitively require a speculum exam in the ED. Those presentations are;

  1. Cervical shock – vaginal bleeding with associated hypotension and bradycardia. This is due to products on conception stuck in the cervix, and causing a vagal response. Removing these products will reverse the shock.

  2. Heavy PV Bleeding – similar idea as above, remove clots or products of conception, in this instance to encourage the uterus to contract and slow bleeding.

  3. Suspected vaginal foreign body – this is obvious. These need to be removed to prevent infection and potential toxic shock syndrome.

The article goes on to argue against doing speculum exams in certain presentations. Here are the instances it argues against speculum exams;

  1. Light bleeding in early pregnancy – speculum exam does not rule out ectopic and ultimately that is the priority over whether something is a threatened vs inevitable miscarriage. Imaging and likely follow up will be necessary in these patients regardless of speculum exam.

  2. Suspected PID or torsion – suspicion of either of these diagnoses will require further testing, rendering the examination superfluous. Some combination of imaging, swabs, or empiric treatment will all be necessary regardless of pelvic examination.

A prospective cohort study in 2011 surveyed providers in the emergency department to ask whether pelvic examination changed management plans or not. 171 of the 187 patients (91%) in this study did not have a change in clinical plan before and after pelvic examination.

While neither of these articles are arguing against speculum examinations as an important tool for emergency providers, they are arguing against speculum examinations for all female patients with lower abdominal pain. The procedure is invasive, time intensive given space limitations, and some of the actual exam findings (adnexal tenderness) are nonspecific and will require imaging or other testing anyways. Should we as a practice reexamine the clinical use of this procedure? Should our threshold for doing speculum examinations be higher?

 

Brown J, Fleming R, Aristzabel J, Gishta R. Does pelvic exam in the emergency department add useful information? West J Emerg Med. 2011 May;12(2):208-12. PMID: 21691528; PMCID: PMC3099609.

Mackenzie, J., & Beech, A. (2024, January 11). Procedure: Speculum examination. Life in the Fast Lane • LITFL. https://litfl.com/procedure-speculum-examination/ 

 · 

Wide Complex Tachycardias and Dual Sequence Defibrillation

 ·   · 

Wide complex tachyarrhythmias refer to abnormal rapid heart rhythms characterized by widened QRS complexes on an electrocardiogram (ECG). These arrhythmias can be life-threatening and require prompt evaluation and management. The etiology, clinical features, and management strategies for stable and unstable patients differ, and in some cases, an electrical storm may occur, necessitating advanced interventions like dual sequential defibrillation.

Etiology:

Wide complex tachyarrhythmias can have various causes, including:

  1. Ventricular Tachycardia (VT): Most common cause, often associated with structural heart disease, myocardial infarction, or scar tissue. Appropriate medical care is to assume that any wide complex tachycardia is VT until proven otherwise.

  2. Supraventricular Tachycardia (SVT) with Aberrancy: When a supraventricular origin rhythm encounters a conduction abnormality, it may result in a wide complex appearance on the ECG.

  3. Pre-excited Atrial Fibrillation: In the presence of an accessory pathway (WPW), atrial fibrillation can conduct rapidly to the ventricles, leading to a wide QRS complex.

Management for Stable Patients:

  1. Identification of Underlying Cause: Determine if the arrhythmia is ventricular or supraventricular in origin.

  2. Antiarrhythmic Medications: Administer medications such as amiodarone, procainamide, or lidocaine depending on the underlying rhythm.

    1. Amiodarone (preferred agent in setting of AMI or LV dysfunction) – dosing is 150mg over 10min, followed by 1mg/min drip over 6 hr.

    2. Procainamide is a potential agent. Did better in the PROCAMIO trial over amiodarone. Initial dosing is 20-50mg/min until arrythmia breaks (max 17mg/kg or 1 gram) then maintenance of 1-4mg/min x 6hr.

  3. Electrolyte Correction: Address any electrolyte imbalances, especially potassium and magnesium.

Management for Unstable Patients:

  1. Immediate Cardioversion: Synchronized electrical cardioversion is the treatment of choice. The usual dosage for synchronized cardioversion is 100-200J. (Note if the patient loses a pulse, in conjunction with started ACLS, the treatment option becomes unsynchronized cardioversion, or defibrillation).

  2. IV Antiarrhythmic Medications: Amiodarone or procainamide may be administered while preparing for cardioversion. Lidocaine is also a potential agent.

  3. Advanced Cardiovascular Life Support (ACLS): Follow ACLS guidelines for managing cardiac arrest, including chest compressions and airway management.

Electrical Storm and Dual Sequential Defibrillation:

An electrical storm is a term used to describe the occurrence of multiple sustained ventricular arrhythmias within a short period. It is a life-threatening situation that may be refractory to standard treatments.

Dual Sequential Defibrillation (DSD):

  • In cases of resistant ventricular arrhythmias, dual sequential defibrillation involves using two defibrillators almost simultaneously to deliver two shocks.

  • The goal is to increase the energy delivered to the heart, potentially terminating the arrhythmia.

  • This approach is considered in refractory cases where conventional defibrillation has failed.

 

Procedure for DSD:

1.       Apply both sets of pads, adjacent to one another, and not touching (see the diagram from RebelEM).

2.       Charge both monitors to max dosage (200J for biphasic, 360J for monophasic).

3.       Charge and simultaneously activate the defibrillation/shock button on each monitor.

4.       Continue with compressions and ACLS.

5.       Consider a beta-blocker (esmolol) bolus, and consider holding epinephrine dosing to limit cardiac excitation.

Sources:

 https://rebelem.com/dual-sequential-defibrillation-dsd/

https://pubmed.ncbi.nlm.nih.gov/27354046/

https://pubmed.ncbi.nlm.nih.gov/8144780/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711501/#:~:text=A%20wide%20complex%20tachycardia%20(WCT,%3E120%20milliseconds%20(ms).

 ·