Antibiotics for chest tubes

Things to keep in mind:

Prophylactic antibiotics for surgical patients in tube thoracostomy is usually limited to 24hrs duration and is 1st generation cephalosporin. It is meant to cover s. aureus the most common organism found in post traumatic empyema

increasing antibiotic use is leading to increase incidence of drug resistance

Potential infectious complications of penetrating or blunt chest trauma:

  • Post Traumatic Empyema
  • Pneumonia

Literature is mixed on whether antibiotics should be given for chest tubes placed for trauma.

In 1998 EAST guidelines gave a level 3* recommendation to give antibiotics prophylacticly to reduce incidence of pneumonia based off of Class I and Class II** data. AND there was insufficient data to give prophylactic antibiotics for post traumatic empyema

This recommendation remains controversial because 

  •    In order for antibiotics to be prophylactic they have to be given prior to a procedure and must reach a steady state concentration in the tissue before an incision is made.
  •    In the case of antibiotics given after a trauma has already occurred, the pleura has already been violated regardless of whether it is penetrating or blunt trauma. Therefore antibiotics do not reach needed concentration before contamination has concerned so these antibiotics are considered presumptive antibiotics.
  •    Non standard definitions of pneumonia and empyema were used, as well as various antibiotics were used in the different studies

In 2012 EAST guidelines reviewed the use of presumptive antibiotics for chest tubes (Tube thoracostomy):

They decided that they cannot make a recommendation for or against the routine use of presumptive antibiotics for chest tubes placed for traumatic hemopneumothorax.

Nor are they able to recommend an optimal duration of antibiotic prophylaxis when antibiotics are administered for traumatic hemopneumothorax because there are insufficient published data to support the routine use of antibiotics.

They concluded:

No single published study has been powered to adequately address the practice of administering presumptive antibiotics in TT for traumatic hemopneumothorax to decrease the incidence of empyema or pneumonia. Until a large and likely multicenter, randomized, controlled trial can be performed, the routine practice of presumptive antibiotics in TT for chest trauma will remain controversial.

If you want to read the article it isn’t a long read:
Post by: Dr. Ashley Guthrie, DO

Case of the Week #2 – I can’t pee!!

CC: Urinary retention

HPI: 44 yo F presents with suprapubic abdominal pain since this AM. She also complains of dysuria and denies fever, chills, hematuria, vaginal bleeding or discharge, flank pain, N/V/D, CP, SOB or any other symptoms. This is her third visit to the ED in the past 3 days for urinary retention. On patient’s initial visit, she c/o pelvic pain, dysuria and urinary retention for 12 hours.  A straight urinary catheter was placed, and 2 liters of urine was drained and the pt was d/c’d home and told to follow up with her PMD. Yesterday, pt returned once again to the ED c/o urinary retention during which a Foley catheter was placed and 900 cc of urine was collected. No UTI was documented. Today, pt still c/o a sense of fullness and has been unable to urinate since 4 am despite having the Foley catheter in place and emptying the bag. Pt called her PMD last night during which he prescribed her Ciprofloxacin for a presumed UTI.

PMH/PSH: None

Meds/Allergies: None

Social: Denies

Physical Exam: Vitals: BP 130/84 P 144 RR 17 O2 sat 100% RA Temp 98.2F

General: Awake, alert, in no acute distress, comfortable
Cardiac: RRR , S1 S2, no murmurs
Lungs: CTAB, no rales, no rhonchi, no wheezing
Abd: Soft, with mild tenderness in suprapubic area. No distention. No rebound or guarding
Back: No CVA tenderness
GU: Foley catheter in place with empty bag
Extremities: No edema or rashes. Able to move all extremities
Neuro: AAO x 3

Labs

WBC: 10. 5
Hg/Hct: 13.3/40
Platelet: 215

Na: 141
K+4.6
CL –: 102
CO2: 26
BUN: 9
Cr: 0.83

Urine HCG: Negative

Urinalysis:
Ketones: Small
Blood: Small
Nitrite Urine: NEG
Leukocyte Esterase: Moderate
RBC: 0-3
WBC: 11-20
Bacteria: Rare

Imaging: 

DDX: Vaginal Mass vs Urinary Retention vs UTI

ED Course: 

Upon evaluation, the Foley catheter’s leg bag straps were fitted incorrectly causing a drainage bag obstruction. In the ED, the obstruction was resolved and catheter was successful draining urine.

The reading of the CT abd/pelvis was: CT Abd/Pelvis W/ and w/o Contrast: There is a 9.9 x 9.4 x 9.9 cm vaginal mass, which displaces the uterus cephalad, and likely the cervix and the bladder anteriorly which is quite effaced. The mass is likely centered in the mid and posterior vagina, which is worrisome for a vaginal or possibly a cervical malignancy although could be of other etiology and warrants a follow up MRI. The most worrisome component is anteriorly to the left where there is either a lymph node measuring 3.7 x 2.5 x 4.7 cm or extrusion of the mass. A left ovary is likely seen with an involuting cyst measuring 2.1 x 1.6 x 1.7 cm quite cephalad to the lesion

OB/GYN was consulted. They came down to evaluate the patient and perform a vaginal speculum exam, which revealed a small amount of malodorous thick discharge similar to pus and a palpable mass in left vaginal wall. OB-GYN recommended patient continues to take Ciprofloxacin as prescribed by her PMD and return to the Emergency Dept. in 3-4 days for re-evaluation and admission to the hospital for a Diagnostic laparoscopy

Pt returned to the ED 4 days later, during which she was admitted and underwent a diagnostic laparoscopy, Left salpingo-oophorectomy and resection of vaginal mass. Foley Catheter was inserted in operating room and pt was d/c home from Same day Surgery.

Discussion:

• Acute Urinary Retention (AUR) in women is rare. It is estimated that are 3 cases of AUR per 100,000 women per year.

• The female to male incidence ration is 1:13

• The most common cause of AUR is obstruction. In women, it is usually secondary to anatomic distortion, including pelvic organ prolapse, pelvic masses, or less likely urethral diverticulum.

• Other less common etiologies include neurogenic causes (MS, Cauda equine syndrome, metastatic spinal cord lesion, neuropathy) and infectious causes (cystitis, Herpes simplex (genital), local abscess, PID).

• Evaluation should include: UA with urine cultures, Chemistry, CBC if you suspect infection or massive hematuria, and a bedside ultrasound to verify retention. Then bladder decompression by inserting Foley catheter. Incomplete retention is PVR > 50mL and > 100mL in patients > 65 years of age

• Pearls: Urinary retention in women is rare. Think of a pelvic mass as a cause, especially if urine is clean. Have a low threshold for obtaining a CT Abd/pelvis to confirm diagnosis.

Post by: Dr. Yenis Paez-Perez, DO

 

Who got that stank?

Neutralizing ED Stank

Patients that stink can really hinder an ED. It creates a difficult work environment for ED staff and makes nearby patients, families and visitors uncomfortable. Here are a few ways I came across to neutralize the stank:

Nebulize stuff in the patients room

 

  • Nebulized OJ (works well for malodorous feet)
  • Nebulized coffee (works well for melena)
  • Will partially mask the smell
  • Works better in enclosed rooms w doors

 

image1.JPG

For when you have to remove shoes & socks (malodorous feet):

1. Maalox booties

  • Place feet in large trauma booties
  • Fill w Maalox and allow to soak

2. Towel Soaks

  • Mix warm water, betadine, peroxide and hibiclens (chlorhexidine) in basin
  • Soak towels in solution then wrap feet
  • Wrap feet and towel w blue pad
  • Allow 15 minute soak

3. Topical sodium bicarb

  • Use 1 amp per foot, apply topically
  • Neutralizes most odors
Post by: Dr. David Traficante (@davetraf)
References:
 

Case of the Week #1

CC Chest pain and palpitations

HPI Pt is a 23 y/o male with no PMHx presenting with c/o palpitations, chest pain since last night. Pt states the pain is localized to the mid sternal chest wall with radiation to b/l upper extremities at times. Pt states the pain came on suddenly last night and he didn’t think anything of it so he went to bed. He woke up this morning with same pain and now with associated nausea and dizziness prompting the visit to the ED. Pt has never had pain like this in the past. Denies vomiting, F/C, recent illness, sudden cardiac death in the family other than a 70 y/o uncle who was obese. Pt denies drug use and states he was drinking over the weekend 2 days ago.

PMHx: none

Meds: none

Allergies: none

PSHx: none

Social: occasional ETOH, (-) drugs

Pertinent PE and Vitals: BP 90/62 P 186 RR 22 O2 sat 100% RA

General: Awake, alert, mild distress Cardiac: (+) tachycardic; no murmurs Lungs: CTAB, no rales, no rhonchi, no wheezing Abd: soft, nontender, nondistended Skin: diaphoretic; mild pallor

Pertinent Labs (if any) Troponin: 0.439

DDX: SVT with aberrancy vs VTach

ED Course: Pt placed on cardiac monitor immediately and IVF bolus initiated. Adenosine 12 mg IVP given while rhythm strip running with no change. A second dose of Adenosine 12 mg IVP given again with no change. 150 mg Amiodarone given with improvement of HR from 190’s to 170’s still wide complex. Second dose of 150 mg Amiodarone given with improvement of HR from 170‘s to 150’s and eventually converted to a NSR rate 85. Pt remained in stable condition and BP responsive to IVF. Pt admitted to telemetry and Cardiology consulted. While still in the ED, pt reverted back to wide complex tachycardia. 3rd dose of 150 mg Amiodarone given and recommendation from Cardiology was to try a 20 mg IVP of Cardizem. Cardizem given and pt immediately converted to NSR. Pt started on Cardizem drip and upgraded to the CCU. Pt underwent EPS and AV dissociation was noted. Determination was Verapamil Sensitive Ventricular Tachycardia. Pt remained stable throughout hospital course and started on Verapamil. Discharged on hospital day #3 with follow up with cardiology clinic.

Final Dx:  Idiopathic Fascicular Left Ventricular Tachycardia AKA • Fascicular Tachycardia • Verapamil-sensitive VT • Belhassen-type VT

Discussion:  MC type of idiopathic tachycardia of LEFT ventricle ! It is a reentrant tachycardia typically seen in young patients without structural heart disease ! Verapamil is first line treatment • Dose: 10 mg IVP over 1 minute ! EKG features: • Monomorphic V tach • QRS 100-140 ms (narrower than other forms of Tach) • Short RS interval 60-80 ms • RBBB pattern • Axis deviation depends on anatomical site of re-entry circuit ! Often misdiagnosed as SVT with RBBB ! Keys to dx: • Observe features of VT such as caption/fusion beats, AV dissociation • Usually unresponsive to adenosine, vagal maneuvers, or beta blockers

Post by: Kristen Pena, DO