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Thats really the question we are all asking ourselves…. At least in terms of Chest Tubes!!!

 

FOR THIS VERSION OF TRAUMA TUESDAYS WITH JOSH, WE’RE GOING TO HAVE A SHORT DISCUSSION ABOUT CHEST TUBE SELECTION! (Hold your excitement please).

 

First, What WE KNOW

 

  • Simple PTX get pigtails
  • Crashing traumatic patients get b/l large bore chest tubes (for now)

 

 

SO you’re probably asking yourself what’s the big deal, that covers it right?

Well NO. There are a few things in contention and a few new studies showing us that WE KNOW NOTHING JON SNOW (for those who don’t get the reference you can just stop reading and catch up 7 seasons of GoT, right now, go!)

 

 

  • Traumatic Isolated PTX: These used to get large bore Chest Tubes. This was really the first thing that changed over to 14F pigtail catheters. If you don’t believe me, this was a great study showing that they were equally as effective, and caused way less pain to the patient. https://www.ncbi.nlm.nih.gov/pubmed/24375295
  • Traumatic Hemo/Pneumothorax: These use to get the BIG MAMA 36/38/40 Fr Chest tubes because bigger is better right? Well maybe not. This study (https://www.ncbi.nlm.nih.gov/pubmed/22327984) showed that a 28Fr chest tube is equally as effective, HOWEVER with similar pain scores as the big ones.

 

 

BUT CAN WE DO BETTER? THIS IS FREAKING 2017 FOR CRYING OUT LOUD. THERE ARE ZOMBIE DRAGONS ROAMING THE WESTEROS!

 

YES WE CAN! (AT LEAST WE THINK WE CAN)

 

AT EAST TRAUMA 2017, there was a paper presented showing 7 years of data from University of Arizona, which showed:

  • Nearly 500 patients were treated with a tube for HTX or HPTX during the 7 year study period, 2/3 with a chest tube and 1/3 with a pigtail
  • Pigtails had more fluid drain initially (430cc vs 300cc, significant), and 1 less treatment day (4 vs 5, also significant)
  • Failure rate and insertion-related complications were the same (about 22% and 6%, respectively)
  • The group found that their use of pigtails steadily and significantly increased over the years

http://thetraumapro.com/2017/01/05/east-2017-7-pigtail-vs-chest-tube-does-size-matter/

SO FINAL WORD: HAVE A DISCUSSION WITH YOUR ATTENDINGS/SURGEONS ABOUT USING A MORE HUMANE TUBE, YOU CAN ALWAYS GO BIGGER!

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Deep Neck Space Infections, AHHH!

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WELCOME ONE AND ALL TO THE GLORIOUS DOROS ADMIN MONTH!

 

Today we will be talking about DEEP SPACE NECK INFECTIONS , because they are doozies. Usually these get mis-triaged to SPLITFLOW, so for new 2nd years, be careful!

 

THE BASICS

  • The neck/pharynx is one of three potential spaces that can cause deep neck space infections
    1. retrophanygeal space
    2. submandibular space
    3. parapharyngeal space
  • Usually are PolymicrobialImage result for deep space neck infections em

     

     

     

    HOW DO THEY PRESENT??? (The starred ones are really concerning)

  • Trismus *******
  • Swelling below angle of mandible
  • Lymphadenopathy
  • Poor handling of oral secretions ******
  • Asymetric pharyngeal swelling
  • Odynophagia (painful swallowing)
  • Muffuled voice ***** 

     

     

    Differential?

    Based on the symptoms, concern

     

    • Peritonsillar Abscess, Retropharyngeal Abscess
    • Ludwig's Angina
    • Epiglottitis
    • Lymphoma
    • Lemierre's Syndrome
    • Parapharyngeal abscess
    • LIST GOES ON!!!!

     

    BUT JOSH!?? HOW DO WE DIAGNOSE THESE????

    IMAGING IMAGING IMAGING

    When in doubt, get a CT with IV contrast to evaluate for deep neck space infections. However there are some signs on Neck Soft Tissue XR. Look for widening of the pre-vertebral spaces.

    Image result for retropharyngeal abscess x ray

     

     

     

    TREATMENT?????

    AIRWAY AIRWAY AIRWAY, then maybe some ABX/Drainage

    If you think that their airway is compromised, get all your airway equipment ready, monitor them, get ENT on board early, intubate early, possibly in the OR with ENT.

     

     

    TAKEAWAY POINTS:

    If you have someone in SPLIT with muffled voice, 1 finger trismus, with difficulty swallowing these patients, upgrade them immediately, watch their airway, get imaging and consultants on board early, and DON'T PANIC (or do.....) 

     

     

     

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Respiratory fRiday: Platypnea, platypus, orthodeoxia, orthodontics?

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Platypnea-orthodeoxia:
* What's that you say? 
- dyspnea and deoxygenation when moving to SITTING UPRIGHT from supine
= wait, that's not normal!
= improved with lying FLAT
- due to INTRAPULMONARY shunting when moving UPRIGHT
​
- suspect with:
= hepatopulmonary syndrome
- possible mechanism of vasodilation and thus increased perfusion of capillaries at lung BASES (which are least oxygenated)
- liver cirrhosis- see this in ~40% of cirrhotic patients
- portal HTN
- hepatitis
- look for finger clubbing!
- pulmonary congestion at bases
​
= AV shunting
= ASD or PFO w/ shunting
= ARDS = rare causes
- Pericardial effusion/restrictive pericarditis
- Significant PE load
- Ileus
* Why do I care? 
- Treatment in the ER: 
- Increased mortality in cirrhotic patients especially with PO2 <60mmHg
- LIVER TRANSPLANT: definitive (but lower post-transplant survival)
- TIPS: decrease shunting, improved gas exchange (theoretical)
- Nitric Oxide Synthesis inhibition or TNF inhibition: no evidence yet
 
- MDM:
- not all respiratory distresses = CHF, pneumonia or PE
- consider extra-pulmonary contribution to SOB
- not all treatments will work all the time
- keep an eye out for variation and be suspicious something else is going on
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