Chest drain devices

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Folks.

This argument is like the "where to do resuscitation" discussion of a
couple of weeks ago. It is principles vs preferences 

PRINCIPLE -  standard of care
PEREFERENCE - how to meet this standard based on:
	- Condition 
	- Situation - 
	- Knowledge and skill
	- Equipment available

Not every technique is right for every situation. Use the one that
provides the best care for the patient at the time that the patient is
being cared for.

The principle is that the chest needs to be drained. The preferences is
"how to do it' in YOUR personal hands and in the SITUATION that is
presented to you, your personal SKILL in the various types of
procedures, the EQUIPMENT that is available, and the CONDITION  of the
patient. Analyze these factors then make your choice as to what is in
the best interest of the patient

How you can personally do it best based on the above is not the same as
how I can do it best. We can discuss the pros and cons of the various
methods of meeting the standard but it all comes down to the principles
vs preferences as laid out above when the patient is lying on the roller
in front of you

Norman

Norman McSwain Jr, MD FACS
Trauma Director Charity Hospital
Professor of Surgery
Tulane University School of Medicine
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Aruni Sen
Sent: Thursday, February 28, 2008 2:28 AM
To: Trauma & Critical Care mailing list
Subject: RE: Chest drain devices

Armed with knife/needle and a strong enough hand, every technique can be
dangerous.

If one knows what to do, small size (12Fr) drain inserted over guide
wire is LOT less distressing for the patient - and does the job if there
is no blood to clot it off.

I am surgically trained so not scared about sharps as the popular belief
goes....

________________________________
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Matthew Reeds
Sent: 27 February 2008 11:30
To: trauma-list at trauma.org
Subject: Chest drain devices


For trauma (as in most other cases as well) there is only 1 appropriate
chest drain method - a large bore chest drain inserted with an
open/blunt dissection technique. Not only will this drain air, but it is
wide enough to drain blood and reduce the potential for clotting of the
tube. Needless to say, as everyone is no doubt aware having heard it
thousands of time, it is inserted WITHOUT the trocar.

As alluded to, the Seldinder technique is used by physicians for
patients with spontaneous primary pneumothoraces and medical pleural
effusions who don't like the procedure/have no experience of the
open/blunt dissection technique - which is in fact relatively easy,
quick and simple. The only time I ever use a Seldiner technique are in
patients post cardiac surgery where there is a reactive effusion and is
not clotted and a Seldinger drain will suffice.

HOWEVER, people mistakenly assume that the Seldinger technique is
atraumatic, when this is not the case. I would say that this can be EVEN
MORE traumatic than the "traumatic" open/blunt dissection technique. I
have seen patients where the needle/guide wire/drain has gone into the
lung parenchyma, bronchus, trachea, oesophagus, pulmonary/hilar vessels.
great vessels and even the left ventricle. The left ventricle case was
when I observed a junior colleague drain a haemothorax and he was
pleased that he had successfully drained it as he drained over 1.5l. He
was ignorant of the fact he was draining it too well and that the drain
was aimed straight at the apex of the heart, pulsating, rapidly draining
fresh bright red blood in spurts into the drain bottle and that the
patient became rapidly drowsy, pale & SOB!!...........luckily the
patient survived as he went straight to theatre for a thoracotomy and
oversewing of his cardiac perforation. Just one of the many reasons for
not using Seldinder chest drains.

Matthew


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