The UK National Health Service’s National Patient Safety Agency published a report entitled ‘Risks of chest drain insertion’, reporting 12 deaths and 15 cases of serious harm related to chest drain insertion over a three year period. They issue the following recommendations under the title ‘For IMMEDIATE ACTION by the NHS and independent sector – Deadline for ACTION COMPLETE is 17 November 2008’:
Clinical governance leads in local organisations should audit current practice and develop local policies to ensure:
Chest drains are only inserted by staff with relevant competencies and adequate supervision
Ultrasound guidance is strongly advised when inserting a drain for fluid
Clinical guidelines are followed and staff made aware of the risks
Identify a lead for training of all staff involved in chest drain insertion
Written evidence of consent is obtained from patients before the procedure, wherever possible
Local incident data relating to chest drains is reviewed and staff encouraged to report further incidents
A series of subclavian vein catheterisations is described in patients using the supraclavicular approach, with a high success rate and few complications. 290 of the 370 patients were mechanically ventilated at the time of the procedure
How they did it:
The point of needle insertion was identified 1 cm cephalad and 1 cm lateral to the junction of the lateral margin of the clavicular head of the sternocleidomastoid muscle with the superior margin of the clavicle (claviculosternocleidomastoid angle)
The direction of the needle was indicated by the line that bisects the claviculosternocleidomastoid angle with elevation 5–15 degrees above the coronal plane.
The needle was advanced slowly with a constant negative pressure in the syringe.
The vein was usually punctured between the clavicle and the attachment of the anterior scalene muscle to the first rib.
The subclavian artery is situated posterior and slightly superior to the vein; if palpable, the pulse of the artery could be the important landmark
The depth of catheter insertion was 14 cm for right side and 18 cm for left side catheterization.
Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in mechanically ventilated patients: analysis of 370 attempts Anesthesiology. 2009 Aug;111(2):334-9 EMRAP.TV has a video on supraclavicular central line insertion here
Small head movements can cause significant tracheal tube migration in infants unless the tube is adequately secured.
Many use a version of the Melbourne strapping method:
1. Equipment required: Silk suture (cut off needle), ‘Cavilon’, elastoplast cut into 3 strips – 2 trouser shaped, and one with a 4cm hole in middle.
2. Apply Cavilon to face (a barrier film to protect the skin) over the area shown by red blobs in the picture.
3. Tie the suture around the tracheal tube. This marks the tube position at the mouth, and allows the tube to be held in place during fixation and when the tapes are later changed.
Pull the two ends taut across both cheeks.
3. While the suture is being pulled taut, place the first ‘trousers’ so that the undivided end is along the cheek (over the tape). The lower ‘leg’ is placed between the lower lip and the chin.
The upper ‘leg’ is folded back on itself to make it easier to removed at a later stage. It is then wound around the tracheal tube
4. The second set of ‘trousers’ is then applied on the other side, once again with the undivided end over the cheek and suture.
The upper ‘leg’ goes between the nose and the top lip and the lower leg is wound around the tracheal tube.
5. Finally the third piece of elastoplast is placed so that the tube goes through the hole
and applied over the other tapes. If there is an orogastric tube this should also go through the hole. The tube is now secure for transfer.
A randomised controlled trial on 200 anaesthetised, tracheally intubated adults compared four methods of nasogastric tube placement, looking at success rates, time to insertion, and complications.
The four groups were: control, using a ureteral guidewire as stylet, a slit endotracheal tube as an introducer, and head flexion with lateral neck pressure. All intervention groups were more successful than the control group. The time necessary to insert the NG tube was significantly longer in the slit endotracheal tube group, which also had the highest bleeding rate. Complications were fewest in the flexion group. Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study Anesth Analg. 2009 Sep;109(3):832-5
A child with status epilepticus has been stabilised and intubated and is awaiting admission to the paediatric intensive care unit. You decide to insert a nasogastric tube. The nurse asks the following questions:
1. What size gastric tube would you like?
[EXPAND Answer]A general guide is twice the size of the uncuffed tracheal tube.
A four year old for example would usually need a tracheal tube size of 5.0mm internal diameter (age/4 +4), so would need a 10 Fr gastric tube.
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2. To what length are you intending to insert it?
[EXPAND Answer]A formula based on height of the child can be used, so get your tape measure or length chart out:
For neonates < 2 weeks and children >8 years 4 months a method called NEMU (nose-ear-midxiphoid-umbilicus measurement) may be used.
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3. How will you confirm placement?
[EXPAND Answer]It is very likely this child will get a post-intubation chest radiograph and the gastric tube tip can be visualised on that. However non-radiological tests should be used and pH testing of the aspirate is recommended, looking for pH<6
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After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.
Easy! larks head knot
1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved Anaesthesia. 2007 Jun;62(6):637
Smaller self-inflating bags produce greater guideline consistent ventilation in simulated cardiopulmonary resuscitation
A comparison between two sizes of self-inflating resuscitation bags revealed improved adherence to resuscitation guidelines with the smaller bag. Student paramedics were more likely to produce suboptimal tidal volumes and ventilation rates with a 1500ml bag than a 1000ml bag during simulated ventilation of an artificial lung model.
BMC Emerg Med. 2009 Feb 20;9:4 http://www.ncbi.nlm.nih.gov/pubmed/19228432
Full text at http://www.biomedcentral.com/1471-227X/9/4
An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO
Emergency physicians at Singapore General Hospital found flow rates to be similar when comparing the tibia with the humerus as sites for adult IO access. The EZ-IO had a very high insertion success rate. It took about 12 minutes to infuse a litre of saline, which drops to about 6 minutes if a pressure bag is used.
Am J Emerg Med. 2009 Jan;27(1):8-15 http://www.ncbi.nlm.nih.gov/pubmed/19041528
Trauma scissors vs the Rescue Hook, exposing a simulated patient: a pilot study
American military investigators compared traditional trauma scissors with the ‘rescue hook’ (a hooked knife with the cutting edge on the inside of the hook) in rapidly removing the clothes from a simulated casualty. An army desert combat uniform and boots were removed more quickly with the rescue hook, which was favoured by the combat medics employed in the study. We don’t have data on how it would work on denim, leather, or belts, but it looks pretty good. I just want to know if it’ll go through a sternum before I trade in my trauma scissors.
J Emerg Med. 2009 Apr;36(3):232-5 http://www.ncbi.nlm.nih.gov/pubmed/18155382
A volunteer study showed that tourniquets were just as effective at occluding distal blood flow measured by doppler signal when placed below the elbow or knee compared with above those joints. A makeshift windlass tourniquet, a rubber tube tourniquet, and a blood pressure cuff were all effective. Digital ‘pressure point control’ failed to maintain control of brachial or femoral artery flow. Tourniquets Revisited J Trauma. 2009 Mar;66(3):672-5
