Thread by @KK_medicine

Today I gave a brief presentation on why we should be doing ALL (yes, I mean all) chest tubes ultrasound-guided.

I learned a lot making the presentation, so here’s a thread 🧵 to review it for my #embound, #MedStudentTwitter, and #MedTwitter friends 1/17

Background: Chest tubes are SUPER common, true surgical and EM 🥖+ 🧈, but did you know the incidence of complication in emergency situations is 14-30%?

THAT IS A LOT!! 2/17

Complications vary, but tend to be 4 main things:

•Subcutaneous positioning
•Intraabdominal placement
•Transdiaphragmatic placement
•Intercostal artery injury 3/17

But we can’t be THAT bad right? We are #BAFERD! Well, Dr. Taylor and friends studied some residents to see... 4/17

They asked EM residents to mark the 4th and 5th intercostal space based on visual landmarks. These were the results with green being ✅ and red being ❌. Then they trained them on US and had them repeat their markings. This is the before and after of that training: 5/17

But there’s more! Here are three other studies that show we can’t reliably find the 4th and 5th intercostal space. 6/17

So now I’m like... 7/17

To which you may respond “I know my physical landmarks, it’ll be fine!” 8/17

The problem is, Dr. Gray and friends found that EVEN IF you find the 4th and 5th intercostal space, up to 20% of patients have their diaphragm cross the 5th ICS during a respiratory cycle! 9/17

So now it’s a double yikes. We suck at finding the “correct space”, and even when we do, anatomically there is a chance we STILL hit the diaphragm! So what is it time for? It’s time for the ultrasound, baby. 10/17

We have 3 simple goals of the ultrasound-guided chest tube:

1. Detect the correct insertion site
2. Locate and exclude vulnerable intercostal artery
3. Confirm intrapleural positioning

Any probe will work but I suggest phased-array or curvilinear in emergent settings 11/17

To find the correct insertion site, we:

•Evaluate the diaphragmatic range of excursion during a full cycle of ventilation

•choose the lowest site for tube insertion while avoiding injury to the diaphragm

12/17

To locate and exclude the intercostal a. we take it back to med school anatomy:

- Scan using Color-Doppler
- Remember the intercostal artery most commonly lies on the upper third of the intercostal space

13/17

This is how it’ll look. If you’re ✨fancy✨ you can turn on M-mode to what the waveform of the artery 14/17

Lastly, we put in the chest tube using surgical technique and confirm intrapleural position

•Chest tube will appear as a hyperechoic arc over a black circle causing posterior shadowing
•Assess subq tissue to ensure no tracking
•Reassess intercostal a. flow with doppler
15/17

And now you’ve done it! You successfully avoided iatrogenic injury using an ultrasound to guide chest tube placement! 16/17

Finally, please check out my sources which were all AWESOME article and major thank you to the authors for their tireless efforts continuing the understanding of medicine! 17/17 #meded #MedTwitter #MedStudentTwitter