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Trauma Surgeons Gone Wild - Kenji's Top 8 Tips on Chest Tube Insertion

Kenji Inaba, MD and Stuart Swadron, MD, FRCPC
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17:20
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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03:42

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EMRAP 2019 June Written Summary 367 KB - PDF

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Zev -

Thank you, Kenji. What is your opinion on the knot to secure the tube? The technique I see used most often is the "Roman sandal" with a series of wraps and square knots, but this is prone to slippage and not the fastest method. Dr. Leigh Evans, the director of simulation at Yale, advocates for using the clove hitch or a series of half hitches, which is both faster than the Roman sandal and also slip-proof.

Tracy G. -

From Dr. Inaba:

Zev,

Thanks so much for the great comment.

I agree, there are many ways the tube can be secured and I think the critical take home is to ensure that whatever method you choose, it keeps the tube from slipping out.

The problem with the "roman sandal" wrap is that if the suture slips down the chest tube towards the skin, it will no longer be tight. I prefer to wrap the suture around the chest tube a few times to give it some cling, but at the level of the skin so as to prevent slippage. A larger gauge suture is helpful, and having a second tie down point with tape is a good idea as well. The highest risk time frame for tube dislodgment is right after they leave the resuscitation bay, as the patient gets transported and transferred to the CT gantry or OR bed or into the ICU.

Thanks again and all the best, Kenji

Dallas Holladay, DO -

Probably not something surgeons are doing but chest tube insertion is a perfect time for a serratus anterior plane block. Use long acting for continued pain control.

Jason A. -

I totally agree. A Serratus or PECS block seems to work very well. Especially true for patients with rib fractures. If they’re stable enough to wait ~10 minutes for the block to work it’s a very nice strategy.

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