Small-bore Catheter (6-12 F) Thoracostomy Tube Placement

Small-bore catheter kit includes:

• Small-bore catheter (6-12 F)
• Trocar
• Finder needle with syringe
• Guide wire
• Heimlich flutter valve (one-directional)
• 11-blade scalpel
• Local anesthetic with additional needle and syringe
• Sterile drapes
• Sterilizing solution

Indications:

• Pneumothorax (especially stable, non-traumatic, spontaneous pneumothorax)
• Pleural effusion drainage in the unstable patient
  • Large-bore chest tubes are still recommended for more viscous effusions such as empyema or hemothorax  

Step-by-step Guide:

1. Prepare the chest tube atrium and ensure appropriate length tubing is available for low wall suctioning once the procedure is complete
2. Place the patient in either a lateral recumbent or supine body position with the head of the bed elevated to 30-45 degrees, or in a seated position with the patient leaning slightly forward for posterior tube placement (i.e. tube placement for drainage of pleural effusions, ultrasound guidance is recommended for posterior tube placement similar to with thoracentesis both to identify the location of the effusion and due to the increased presence of vascular structures between the rib spaces posteriorly)
3. Identify the location of insertion, usually the 4-5^th intercostal space at the mid-axillary line (similar to large-bore chest tube placement) at the level of the nipple. Remember the “safety triangle” bordered by the lateral edges of the pectoralis and latissimus dorsi muscles where there is a decreased risk for damage to underlying vascular, nervous, and organ structures
4. Sterilize the skin surrounding the site of insertion and drape the patient accordingly using the drape provided in the kit, or by using sterile towels if preferred (remember to leave the nipple exposed to assist with identifying landmarks during catheter placement)
5. Measure the small-bore catheter in front of the patient’s chest to determine the appropriate depth of insertion in a manner which ensures placement towards to superior aspect of the chest with all side ports within the pleural cavity (remember, the catheter can be withdrawn but not inserted further once the procedure is complete, similar to placing a central venous catheter)
6. Generously anesthetize the skin at the desired site of insertion, advancing your needle deeper over the superior aspect of the rib to minimize the risk of damage to the neurovascular bundle, withdrawing prior to injecting lidocaine as the needle progresses through the soft tissue. Be sure to anesthetize the parietal pleural during this process, as it is fine for the needle tip to pass into the chest cavity
7. Gently advance the finder needle over the superior aspect of the rib through the intercostal musculature similarly to the previous step while steadily drawing back against the syringe plunger as the needle tip advances. The plunger pressure will give way once access into the pleural cavity is achieved. Consider loading the finder needle syringe with several mL of sterile water for visualization of air bubbles in the syringe to assist with this step
8. Once access to the pleural space has been achieved remove the syringe from the finder needle and insert the guide wire into the back of the finder needle passing the wire into the pleural cavity in such a manner that leaves most of the wire hanging outside of the patient
9. Remove the needle from the patient and make a small incision in the skin at the base of the guide wire using the provided 11-blade scalpel
10. Pass the dilator over the guidewire and into the pleural space feeling it give-way once it has pierced the parietal pleura and entered the thoracic cavity. Be sure to visualize the guide wire exiting the back of the dilator prior to insertion to ensure the wire is not accidentally lost within the chest. The dilator may be removed once this step is complete
11.  Pass the small-bore catheter within its trocar over the guide wire and into the pleural space in a manner that ensures all side ports are within the space. Generally, the first black indicator line can be used for small and thin patients, the second black line for the average adult, and the third black line for large adults. Similarly to the above step, ensure the guide wire is visualized exiting the back of the trocar prior to insertion.

HD – Pigtail Chest Tube Insertion | EM:RAP (emrap.org)

ED Operations Lecture 

Dr. A. Ross, MD 
POC Troponin will be leaving the ED
High Sensitivity Troponin (hsTnl): Less than 15ng/L in females and less than 20ng/L in males is interpreted as negative; anything above is considered positive.
-Reported in whole numbers-Significant delta is an increase in 15 ng/L (over 2 hours); note a fall greater than 15 is significant too. -Must Repeat in 2 hour intervals-Will take about 30-45 min to result. T2 Bacterial PCR: rapid diagnostic ecoli, s. aureus, klebsiella, pseudo, E. faecalis-TAT 3-5 hours Who: septic patients Benefit?: Deescalation of antibiotics once resulted.

Level 1 Activation Criteria: SBP <90mmHg, Resp compromise or impending, EP Discretion, Blood resuscitations to maintain VS in transport, GSW or severe penetrating trauma to neck, chest, or abdomen, GCS <9 with mechanism attributed to trauma.NOTE: GSWs to the head and going to SICU (call trauma on these) do not need to activate Level 1 on these. 
Shunt Series: power plan in cerner; rad VP shunt series (orders all plain films) 
TEG Stay Tuned
Continue to place Intend to Admit Order in Cerner on people you know will admit.

One Pill Can Kill 

Dr. R. Lund, MD 

CCB, TCA, Lamotil, Opiates/Opioids, Camphor, Clonidine, Antimalerials 
Opioids: Naloxone dosing peds: 2mg IV q3-5BB Tox: hypoglycemia and bradycardia; glucagon and or high insulin protocol (consult tox.)CCB: Dihydro and Non-Dihydro; Txt: supportive care; Poison Control ConsultationOil of Wintergreen: Salicylate Toxicity; Toxidrome: Nausea, Vomiting, Tinnitus, Txt: Urinary Alkalization Sulfonylureas: Admit for 24 hours, give either PO or IV. Txt: Octreotide infusion Clonidine/Imidazoles: A-2 agonist, high dose narcan and supportive care measures. symptoms: lethargy and or coma typically. Camphor: Txt: Benzos and Phenobarb for seizures; TCA: CNS, anticholinergic, and QRS prolongation; QRS 100ms< is pathologic; Tx: Benzos and Bicarbonate, Lamotil; loperamide +/- atropine; symptoms: anticholinergic and opiate toxidrome picture; txt: narcan Toxic Alcohols: Ethylene Glycol, Methanol, and Isopropyl Alcohol (rubbing etoh): Isopropyl: ketonuria; supportive care Methanol: de-icers, HA, Metabolic acidosis, breaks down into formic acid, give fomepizole or ETOH to compete out A. dehydrogenase Eth. glycol: txt: fomepizole, dialysis, and bicarb for acidosis. 

SJS/TEN 
Dr. Slaven, MD 

SJS <10%; TEN 30%<Hx physical exam key; Workup: CXR, CBC, CMP ESR/CRP SCORTEN Score predictor availableRemove inciting factor Pathogenesis: Sulfa drugs; typically first 8 weeks Consults: Optho, Uro, OBGYN 

Pemphigus Vulgaris & Bullous Pemphigoid

Dr. Martinez,MD 
PV: More common
Pemphigussssss is SSSSuperficial Age Range 40-60yo Autoimmune Dz; Ab to DSG 3&1+Nik sign; Flaccid bullae clinically, mucus membrane involvement <10% TBSA TxT: systemic steroids and rituximab IV; 2nd line: Dapsone, Mycophenolate and IVIG. Non-adhesive dressing application
BP: Pemphigoidddd is NOT Superficial Disease of elderly F>M 1.3-1autoimmune disorder vs. basement membraneTense blisters clinically; pruritic, tense bullaePruritus is more apparent clinicallyTxt: Topical steroids preferred; IVIG can be used as well per derm’s recs. 

Stress & Burnout: 

Dr. Huecker, MD 
Stress= perception of perceived threat. if perceived as negative, research says that this can have negative impacts on healthif perceived as positive=can have beneficial effects on personal potential Stress can impede performance, determined by the individual’s “appraisal” of the situation. Hormesis: phenomena of dose response relationships and over prolonged periods of time can have strengthening effects. Dose of poison a day will make us better. Connect with people daily: compassion does to deplete resourcesOptions to cope: exercise, therapeutic writing, gratitude recognition, thousands available 

Necrotizing Fasciitis: Dr. Lehnig, MD 
Diagnosis: Surgical Exploration CT 90% vs. MRI 86% sensitivityTreatment: “Early Surgical Debridement” Antibiotic Regimen: carbapenam or Zosyn +Vanc, dapto, or linezolid +clindamycin for antitoxin effects

Staphylococcal Scalded Skin Syndrome (SSSS): Dr. Edwards, MD 
Mostly less than 5 yo; if in adults typically immunocompromised Clinical Exam: +Nikolsky’s sign and will spare mucosal surfaces; + fever typically Diagnosis: Clinical Exam; look for other infections that precipitated the infection. Treatment and Disposition: Typically burn unit admission, Antibiotic Regimen: Typically MSSA but if there are risk factors for MRSA use coverage for MRSA. 

EMTALA : Dr. Royalty, MD 

Emergency Medical Treatment and Active Labor Act#1: Medical Screening Exam (Everyone gets this no questions asked)#2: If you ID an emergency condition, you must treat and stabilize this, if hospital can’t manage, must get accepting physician to transfer to higher level of care#3: If OSF needs to transfer patient because of lack of ability to care for patient, facility is required to accept patient despite ability to pay, etc. Transfers: All pertinent records and imaging should accompany patient or be sent electronically ASAP. 

Decisional Capacity: Dr. Yff, MD
Informed Consent: understand treatment, potential risks and benefits, and reasonable alternatives

4 Components: relevant info, appreciation of consequences (insight), reasoning of choice & 
communicating a choice.
Estimated, 48% of patients hospitalized are not capable of making decisions in a hospital setting MacCAT-T: decisional tool to evaluate capacity. 

Treatment of Non-Emergent Hyperglycemia in the ED: Sue McGowan, APRN 
Diagnosis: Glucose >126 fasting, a1c over 6.5%, and Random BG >200 + symptoms Targets for Diabetes: Premeal BG 80-130, post prandial <180, a1c <7Treatment: Diet and exercise-> Metformin if renal function adequate and no GI intolerance (500mg BID)-> a1c 8.5% (ADA recommends 2nd agent-> a1c 9% (see ADA guidelines)-> a1c Long Acting: 24 hour coverage “peak less”; glargine,basaglar, detemir, degludec (each vial has 30 days 300U)NPH/Intermed acting: onset 1-3 and peak 6-12 hours (NPH and 70:30 insulin very cheap) Rapid Acting: 5-10 min onset peaks1-2 hours (the “logs” and apidra and fiaspInitiating Insulin: basal or NPH 10U/day or 0.1-0.2 U/kg/day goal <130 before breakfast (titrate ever 3 days by increasing 2 U to hit morning goal)Glucose tabs=fastest method to correct hypoglycemia OOH (OTC and cheap)Send prescription for glucagon for 2ndary person to admin for rescue. Diabetes Supplies: glucometer, test strips, lancets, and needles for insulin. Diabetic NP: 10am-6:30pm ULH consult via cerner.

Electrical Injuries: Dr. Leavitt, MD 
Low voltage <600V (most household circuits around 120V)High Voltage 600V<Peds: chewing on electrical cords, must admit these, delayed necrosis of S. labial A. Lighting Injuries: Initiate CPR immediately if pulseless; ruptured TMs, A/C worse than D/C injuries