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:
 

Just because she cannot pee, does not mean “No UCG”

Let’s face it, we’ve all done it. And, believe me when I tell you all the cool cats are doing it, too.  Of course, I am referring to the use of whole blood to determine a woman’s pregnancy status in the Emergency Department using the urine pregnancy test strip. ucg-bcg-photo-brancato

Did you know that the common ICON 25 Beckman-Coulter hCG tests are actually approved for both urine and serum? Don’t feel bad; I didn’t until I read a recent article. Whole blood, which is comprised of serum (54%), hematocrit (45%) and leukocytes/platelets (1%), was rumored to detect a woman’s pregnancy status.  Now, we have research that confirms our suspicions and demonstrates that whole blood pregnancy testing performs quite excellently.

In a study published in 2012, whole blood pregnancy tests were found to be 96% sensitive, 100% specific with a negative predictive value of 98% and positive predictive value of 100%. Translation: Trust a positive test, it will not be wrong.  Can it miss? Yes, it can; however, there’s a good chance that the urine test will be negative at that point, too (5 of 9 that were missed with whole blood testing of the studied 425 pregnancies were also negative on the urine testing—the other 4 of  9 did not undergo urine testing).

As troops on the front lines of medicine, we are presented often with little time to think or to act. We are adroit at putting puzzle pieces together, often with little information. This is our creed and such is our nature.  It is during these critical cases, that the application of using whole blood pregnancy testing has its greatest application.

Post by: Raphael Brancato, DO (@DrRayFields )

TLC: Triple Lumen Complications

Placing central venous cathethers, whether under ultrasound guidance or based off of your landmarks can be difficult and still prone to many complications.  With the increased use and now standard of care for placing central lines with ultrasound guidance you would think we are immune to the “catastrophic” complication of an inadvertent arterial cannulation.  But does ultrasound make us infalliable? Are there other methods that we can use to confirm venous placement of these large catheters?

Traditionally, we have looked at the color and pulsatility of blood coming from the needle hub before placement of the guidewire, but as you can imagine this is known to not be the most reliable; most of us aren’t going to go through the hassle of checking a blood gas off that blood either.

Troianos et al. found that ultrasound guidance reduced the incidence of arterial puncture from 8.4% down to 1.4% during attempted IJV cannulation.  That’s great that it decreased the incidence, but when looking at the complications such as airway obstruction, hemothorax, pseudoaneurysms, AV fistulas and stroke, 1.4% is not something to sneeze at.  So, keep in mind that although it does reduce the frequency of arterial puncture, it does not eliminate it entirely!

Despite the use of dynamic ultrasound guidance, there are still numerous reports of arterial placement of large bore catheters due to a couple reasons: 1. The needle tip may not be seen in the same plane of the ultrasound and confused with the shaft of the needle.  2. The needle may be in the vein, but the needle may move into the artery during placement of the guidewire after most of us have abandoned the ultrasound visualization.  Ideally, after the guidewire is placed we should make it a habit to confirm the guidewire is in the vein before dilating the vessel.

Management of Arterial Cannulation

Despite our best efforts and even the most astute ultrasonographer there is always the potential for an inadvertent arterial cannulation, but what do we do once we have figured that out?

Option 1: Just old fashioned PULL AND PRESSURE: essentially this is exactly as it sounds. You pull out the catheter and apply pressure, just like any other line that is being removed. This is probably most reasonable for femoral artery cannulations, but there still remains a possibility of false aneurysms and AVF as late as 2 weeks after removal with the pull and pressure technique.  Pull and pressure isn’t supposed to be used for carotid or subclavian arterial cannulations.  One convincing piece of evidence is that there is an immediate stroke risk of 5.6% after removing carotid cannulations with this technique.  Of 11,874 internal jugular vein cannulations, 20 ended up being carotid artery cannulations.  19 of these 20 were removed using the pull and pressure technique; six patients suffered complications and two of the patients died.

Option 2: Surgical ENDOVASCULAR repair:  The more preferable method, especially for removal of carotid and subclavian arterial cannulations, is to involve our vascular surgeon colleagues.  Just leave the line secured to the neck and get them involved. Some are going to request a formal ultrasound of the carotid or even sometimes a CT angio of the neck to check for extravasation, pseudoaneurysms, AVF and the location of the catheter.

Key points to remember

  1. Arterial cannulation can occur despite use of ultrasound guidance
  2. The American Society of Anesthesiologit’s guideline for CVC placement states that color and pulsatility are NOT reliable for distinguishing vein from artery.
  3. The pull/pressure technique is associated with significant risk of hematoma, airway obstruction, stroke, and false aneurysm especially when the site of arterial trauma cannot be effectively compressed
  4. Low IJV placement can injure the subclavian or innominate arteries
  5. Endovascular treatment is safe for management of arterial injuries that are difficult to expose surgically, such as those below or behind the clavicle.
  6. Normal Carotid Duplex after removal of a catheter form carotid artery does NOT rule out the possibility of a stroke
  7. False aneurysms or AV fistulae can occur LATE, up to 2 weeks after the “pull and pressure” technique so close follow up is needed

Post by: Dr. Yenis Paez-Perez, DO

 

 

Throwin’ shade at the POKER Trial

There’s been a lot of chatter in the twitterverse surrounding the recent release of the POKER Trial out of Australia comparing ketofol with propofol for procedural sedation.  Their primary outcomes were looking at respiratory complications, including apnea, desaturation or hypoventilation; with secondary outcomes of hypotension and patient satisfaction.  They report “ketofol and propofol resulted in a similar incidence of adverse respiratory events requiring intervention by the sedating physician.” While this is true based on their data, when you start breaking down the airway interventions, propofol did require more instances of the patient requiring assisted ventilation with a BVM.  Call me crazy, but to me that seems a little more of an intervention than just turning up the oxygen flow on the nasal cannula.  Propofol also had a greater rate (8%) of hypotension (SBP<90) when compared to ketofol (1%), and while there were no clinically significant outcomes related to this hypotension, I think it’s still important to note.  It seems like a lot of shade is being thrown (definition here) at ketofol after this trial, but I haven’t closed the door on ketofol yet.  I would still give ketofol a chance, I much prefer not having to bag my shoulder reductions as the propofol wears off and while a BP of 70/40 may not stroke them out in front of you, it still gets my heart rate up a bit.

Post by: Terrance McGovern DO, MPH (@drtmcg)

Gone fishin’

The weather is finally starting to warm up and the fish are biting.  Unfortunately, amateur and pro fishermen alike will also either catch themselves or their friend while out on the waterways this summer.  While a small fishhook lodged in a finger may seem trivial compared to some of the more traumatic injuries we see, the process of removing a fishhook can still be challenging and time consuming.  In this month’s issue of ACEP Now we published four different ways of removing these pesty hooks. Check it out here. 

Post by: Terrance McGovern DO MPH (@drtmcg13)