Pigtail catheter for pleural drainage: Tips to minimize complications

pigtail

Traditionally large-bore tube thoracostomy has been the standard of care for treating many acute intrathoracic pathologies [1]. However, the advent of less invasive small-bore chest tubes, also known as pigtail catheters, has gradually led to a paradigm shift. Pigtails provide a less invasive and often better tolerated alternative to traditional chest tubes and allow for adequate treatment of pneumothoraces and uncomplicated pleural effusions [1-5]. Unfortunately, these less invasive catheters are not without complications – both unique and similar to traditional chest tubes.

Case

A 48 year-old male with a history of hypertension and polysubstance abuse presented to the emergency department (ED) for shortness of breath and was found to have a left sided parapneumonic pleural effusion (Figure 1). The patient underwent thoracentesis and placement of a pigtail catheter using the Seldinger technique to drain the fluid collection. Pigtail catheter placement was confirmed by chest x-ray (Figure 2).

pleural effusion chest x-ray

Figure 1: Chest x-ray with left sided pleural effusion

pleural effusion chest x-ray pigtail catheter

Figure 2: Chest x-ray with the pigtail catheter in the left chest

Case Progression

Despite pigtail catheter placement, there was minimal drainage from the catheter. In collaboration with the inpatient team, intrapleural thrombolytics were administered via the pigtail catheter did not resolve the issue. Although the patient’s chest x-ray did improve after the procedure, the patient continued to deteriorate clinically and became increasingly hypoxic.

A CT angiogram was then performed and showed that the pigtail catheter had been accidentally introduced through the lung parenchyma and was lodged in the left main stem bronchus (Figure 3). This was confirmed on bronchoscopy (Figure 4).

pigtail catheter chest ct in bronchus

Figure 3: Chest CT angiogram showing the pigtail catheter (arrow) in the left mainstem bronchus

bronchoscopy pigtail

Figure 4: Bronchoscopy view of the left mainstem bronchus showing the pigtail catheter

This case highlights one of the more rare and potentially severe complications of small-bore chest tubes. With the increasing utilization of such devices, this case  highlights the need for better education about the indications, complications, and troubleshooting approaches with these pigtail catheters. 

Complications

The overall complication rate for small-bore catheters is lower than their large-bore counterparts, partly because of their smaller caliber. Also unlike traditional large-bore tube thoracostomy, the lack of tactile feedback (not feeling the pleural puncture ‘pop’ with Kelly clamps and then identifying the intrapleural space with the finger) can lead to malpositioning complications. Both approaches, however, share common complications:

  • Most common complication: Chest tube kinking and obstruction [6, 7, 10]
    • Due to the small caliber of the pigtail catheter, it can easily become twisted or kinked between the pleura and lung parenchyma, obstructed within lung fissures, or kinked externally between the body and environment [9].
    • Obstruction may also occur from clotted blood [9] or pleural effusion loculations [12, 13] within the catheter lumen.
      • For loculated effusions and empyemas, an interdisciplinary inpatient discussion should weigh the pros and cons of intrapleural thrombolytics versus surgical drainage and pleurodesis.
      • One often used thrombolytic regimen is the MIST-II protocol, which involves the combination of alteplase (tPA) 10 mg BID plus dornase alfa (DNase) 5 mg BID [13, 14].
  • Laceration of tissue/vessel [2, 3, 6, 8]
    • Can be prevented by using standard landmarks and inserting above the rib margin
  • Air emboli [2, 3, 6, 9]
    • Thought to be due to parenchymal injury resulting in a fistula involving the pulmonary vessels
  • Parenchymal injury [9]

References

  1. Gammie JS, Banks MC, Fuhrman CR, et al. The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 1999;3(1):57-61. PMID: 10323171
  2. Saqib A, Ibrahim U, Maroun R. An unusual complication of pigtail catheter insertion. Journal of Thoracic Disease. 2018;10(10):5964-5967. doi:https://doi.org/10.21037/jtd.2018.05.65
  3. Broder JS, Al-Jarani B, Lanan B, Brooks K. Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety. The Journal of Emergency Medicine. 2020;53(3). doi:https://doi.org/10.1016/j.jemermed.2019.10.003
  4. Vetrugno L, Guadagnin GM, Barbariol F, et al. Assessment of Pleural Effusion and Small Pleural Drain Insertion by Resident Doctors in an Intensive Care Unit: An Observational Study. Clinical Medicine Insights Circulatory, Respiratory and Pulmonary Medicine. 2019;13:1179548419871527. doi:https://doi.org/10.1177/1179548419871527
  5. Kulvatunyou N, Vijayasekaran A, Hansen A, et al. Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend. J Trauma. 2011;71(5):1104-1107. doi:https://doi.org/10.1097/ta.0b013e31822dd130
  6. Remérand F, Luce V, Badachi Y, Lu Q, Bouhemad B, Rouby JJ. Incidence of Chest Tube Malposition in the Critically Ill. Anesthesiology. 2007;106(6):1112-1119. doi:https://doi.org/10.1097/01.anes.0000267594.80368.01
  7. Horsley A, Jones L, White J, Henry M. Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains. Chest. 2006;130(6):1857-1863. doi:https://doi.org/10.1378/chest.130.6.1857
  8. Hyo Jin Kim, Yang Hyun Cho, Gee Young Suh, Jeong Hoon Yang, Jeon K. Subclavian Artery Laceration Caused by Pigtail Catheter Removal in a Patient with Pneumothorax. The Korean Journal of Critical Care Medicine. 2015;30(2):119-122. doi:https://doi.org/10.4266/kjccm.2015.30.2.119
  9. Anderson D, Chen SA, Godoy LA, Brown LM, Cooke DT. Comprehensive Review of Chest Tube Management: A Review. JAMA surgery. 2022;157(3):269-274. doi:https://doi.org/10.1001/jamasurg.2021.7050
  10. Aho JM, Ruparel RK, Rowse PG, Brahmbhatt RD, Jenkins D, Rivera M. Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications. World Journal of Surgery. 2015;39(11):2691-2706. doi:https://doi.org/10.1007/s00268-015-3158-6
  11. Gayer G, Rozenman J, Hoffmann C, et al. CT diagnosis of malpositioned chest tubes. Br J Radiol. 2000;73(871):786-790. doi: https://doi.org/10.1259/bjr.73.871.11089474
  12. Altmann, E. S., Crossingham, I., Wilson, S., & Davies, H. R. (2019). Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema. The Cochrane database of systematic reviews, 2019(10), CD002312. https://doi.org/10.1002/14651858.CD002312.pub4
  13. Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365(6):518-526. https://doi.org/10.1056/NEJMoa1012740
  14. Chaddha U, Agrawal A, Feller-Kopman D, et al. Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement. Lancet Respir Med. 2021;9(9):1050-1064. doi:10.1016/S2213-2600(20)30533-6. PMID 33545086
By |2024-04-14T09:44:45-07:00Apr 12, 2024|Pulmonary, Trauma|

ALiEM AIR Series | Trauma 2023 Module

Welcome to the AIR Trauma Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to trauma in the Emergency Department. 8 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 3 AIR and 5 Honorable Mentions. We recommend programs give 4 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Trauma Module at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Trauma

SiteArticleAuthorDateLabel
Rebel EMTrauma Resuscitation UpdateSalim Rezaie, MDMay 25, 2023AIR
EM DocsUnstable Pelvic Trauma PatientLuke Wohlford, MDJune 3, 2023AIR
EM DocsMaxillofacial TraumaForrest Turner, MDOctober 17, 2022AIR
Rebel EMPATCH trauma trialAnand Swaminathan, MDJune 19, 2023HM
Don’t Forget the BubblesBlast InjuriesAndrew Tagg, MDMarch 16, 2023HM
Don’t Forget the BubblesPenetrating Chest TraumaSarah Davies, MD and Kat Priddis, MDJuly 1, 2023HM
St Emlyns BlogRefresher on Blood Transfusion in TraumaRichard Carden, MDApril 13, 2023HM
RCEMlearningBlast InjuriesAlison Tompkins, MDJune 30, 2023HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us!

Reference

  1. Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275

SAEM Clinical Images Series: Only a Flesh Wound

flesh

A 49-year-old male was triaged to the Fast Track area with complaints of an abrasion to the neck following an assault. The patient was attending a party with his family when “someone started shooting.” The patient believes some stucco or stone fragment from a brick wall struck him in the neck during the initial incident, but his primary concern was for his more seriously wounded family members. He now presents requesting “Neosporin.” His tetanus status is out of date.

General: Well-appearing male in no distress

Neck: Hemostatic wound to his left neck. No significant pain, no hematoma, no bruits.

Neuro: Exam is non-focal

Non-contributory

This is a zone 2 injury to the neck. Despite the small size of the wound, a piece of metallic shrapnel from the splintered bullet is noted adjacent to the carotid on CT imaging. Penetrating wounds can be deceptively innocuous, and a high index of suspicion is required. In cases where the nature of the missile is known, plain films or POCUS may be a reasonable first step, but CT imaging would be definitive.

Development of hoarseness or a Horner syndrome on the affected side may indicate involvement of the carotid sheath, and an angiogram may be considered, though CTA compares favorably to angiography in penetrating as opposed to blunt arterial trauma.

Take-Home Points

  • “Superficial” wounds must be evaluated diligently for any signs of deeper extension, and advanced imaging obtained for any suspicious findings or concerning mechanism of injury.
  • CTA is likely to be adequate in most cases of penetrating trauma, but a role may still exist for angiography in the presence of compelling clinical findings.

  • Goodwin RB, Beery PR 2nd, Dorbish RJ, et al. Computed tomographic angiography versus conventional angiography for the diagnosis of blunt cerebrovascular injury in trauma patients. The Journal of Trauma. 2009 Nov;67(5):1046-1050. DOI: 10.1097/ta.0b013e3181b83b63. PMID: 19901666.
  • Múnera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology. 2000 Aug;216(2):356-62. doi: 10.1148/radiology.216.2.r00jl25356. PMID: 10924553.

By |2023-09-14T13:12:37-07:00Sep 29, 2023|SAEM Clinical Images, Trauma|

SAEM Clinical Images Series: A Rare Cause of Post-traumatic Neck Pain

neck pain

A 15-year-old male presents to the pediatric Emergency Department (ED) for evaluation of neck pain for three weeks. The patient is vague as to the development of his symptoms, but his mother reveals patient was assaulted by peers three weeks ago and has had progressively worsening neck pain and stiffness. The patient states symptoms have gotten to the point where he is unable to turn his head but denies fevers, chills, nausea, vomiting, focal weakness, or sensory changes.

Vitals: Temp: 99.4°F; HR 80; RR 18; SpO2 98% on room air

Constitutional: No distress, sitting rigidly in bed.

Neck: Cervical midline tenderness noted with rigid neck and severe tenderness with manipulation, no swelling, erythema, or masses noted.

HEENT: No pharyngeal injection, no visible masses in the oropharynx, no trismus.

CV: Regular rate and rhythm, no murmurs, rubs, or gallops. Good peripheral perfusion.

Abdomen: Soft, non-distended and non-tender.

Neuro: 5/5 motor function to the bilateral upper and lower extremities, normal sensory examination, cranial nerves intact. Negative Kernig’s sign.

White blood cell (WBC) count: 9.5

Platelets: 639

Glucose: 105

CRP: 128

ESR: 100

CSF: Color- Clear; Nucleated Cells- 1; Protein- 25; Glucose- 6

This patient was found to have septic arthritis of the atlantooccipital (AO) joint, noted on the CT shown above, with joint space narrowing and erosion (red arrow) of the right AO joint with associated soft tissue swelling and effusion. Seen on the MRI is further confirmation of the findings suggested on CT of septic arthritis, with additional noting of attenuation of the prevertebral space of C2/C3 suggestive of phlegmon, bilateral AO joint arthritis, and involvement of the atlantoaxial joint, all of which can be seen on the above sagittal cut of the MRI, with the most notable being the pre-vertebral phlegmon (red arrow).

Septic arthritis of the facet joints is a rarity, particularly in pediatrics and in the cervical spine; case reports largely describe a lumbar location in elderly adults with predisposing comorbidities (intravenous drug use, diabetes, immunosuppression) for spontaneous infection. There are no published case reports of traumatic, pediatric AO joint septic arthritis. This patient developed septic arthritis following trauma. As with peripheral septic arthritis, the most common cause is hematogenous spread, and even non-penetrating trauma can predispose a joint to infection as likely occurred in this case. Septic arthritis of the facet joints presents similarly to spondylodiscitis, generally with fever, neck or back pain, and elevated inflammatory markers such as CRP/ESR. If left untreated, it can be a dangerous and refractory cause of sepsis that leads to deadly complications such as concomitant epidural access formation. Oftentimes patients are initially misdiagnosed and re-present multiple times as the preferred image modality for diagnosis is MRI which is not always readily available or ordered. In general, treatment generally includes weeks-long courses of intravenous (IV) antibiotics, though this patient was discharged on oral antibiotics after significant symptomatic improvement on IV therapy after four days.

Take-Home Points

  • Septic arthritis of the cervical facet joints, namely the AO joint, is a rare cause of neck pain in patients with fever and elevated inflammatory markers, and can present after trauma. Generally, it is hematogenously spread and associated with comorbidities such as diabetes, intravenous drug use, and immunosuppression, it should be considered in patients with refractory symptoms or in which there is strong suspicion as it can have dangerous complications.
  • The preferred imaging modality for diagnosis is MRI, though CT can be useful in making the diagnosis radiographically. Treatment generally consists of weeks of IV antibiotics.

  • Sethi S, Vithayathil MK. Cervical facet joint septic arthritis: a real pain in the neck. BMJ Case Rep. 2017 Aug 3;2017:bcr2016218510. doi: 10.1136/bcr-2016-218510. PMID: 28775081; PMCID: PMC5612571.
  • Narváez J, Nolla JM, Narváez JA, Martinez-Carnicero L, De Lama E, Gómez-Vaquero C, Murillo O, Valverde J, Ariza J. Spontaneous pyogenic facet joint infection. Semin Arthritis Rheum. 2006 Apr;35(5):272-83. doi: 10.1016/j.semarthrit.2005.09.003. PMID: 16616150.

SAEM Clinical Image Series: Snowball Effects

A 13-year-old boy presented to the emergency department with complaints of a right eye injury. Five hours prior to arrival, he was struck directly in the right eye with a snowball resulting in immediate eye pain, localized swelling, some flashes of light in his vision and blurry vision. Prior to arrival, the patient had been seen at an optometry center where puff pressures of his eyes were obtained and the right eye was noted to have an increased intraocular pressure (IOP) of 46 mmHg compared to a pressure of 13 mmHg on the left. He continued to endorse photophobia and mild right eye pain.

Eye:

  • No bony tenderness or crepitus surrounding the right eye
  • Positive blood fluid level in the anterior chamber
  • EOMI
  • On confrontation of visual fields, the patient was unable to count fingers in all fields on the right but could detect light and movement
  • Red reflex could not be elicited on fundoscopic exam
  • On fluorescein exam, no flow of aqueous humor and no corneal abrasions
  • Tono-Pen IOP measurements were 41mmHg in the right eye, and 27 mmHg in the left eye

Non-contributory

The red flags include a history of vision loss and the presence of ocular hypertension with the hyphema. Ophthalmology was emergently consulted for the intraocular hypertension. By the time of evaluation by the specialist, the patient stated that his vision was less blurry and he did not see any spots in his vision. The photos demonstrate progression of the traumatic hyphema from grade IV, to grade II, and then grade I.

 

The emergent conditions that must be addressed include open globe and intraocular hypertension. Ophthalmology IOP measurements were 14 mmHg bilaterally. Visual acuities were 20/40 on the right and 20/20 on the left. A dilated eye exam with the slit lamp could not fully assess the posterior eye structures due to haziness. A metal eye shield was applied to the patient’s right eye, and he was discharged with cyclopentolate and prednisolone acetate eye drops, and an ophthalmology follow-up appointment within 24 hours. The patient was instructed to be on bed rest with the head of the bed elevated and to avoid straining.

 

 

Take-Home Points

  • In traumatic eye injury, pay attention to eye color changes with grade IV hyphema which can be missed unless you compare it to the uninjured side.
  • Look for features of an open globe which include irregularly shaped pupils, delayed consensual light response, extrusion of vitreous, Seidel’s sign (fluorescein streaming of tears away from the puncture site).
  • Beware of intraocular hypertension (>21 mmHg) with high-grade traumatic hyphema which needs to be emergently addressed to prevent optic nerve atrophy and permanent vision loss.

  • Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001 Dec;59(12):1462-70. doi: 10.1053/joms.2001.28284. PMID: 11732035.
  • Gharaibeh A, Savage HI, Scherer RW, Goldberg MF, Lindsley K. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005431. doi: 10.1002/14651858.CD005431.pub2. Update in: Cochrane Database Syst Rev. 2013;12:CD005431. PMID: 21249670; PMCID: PMC3437611.

 

IDEA Series: DIY Suture Kit Station

laceration suture repair closure

In medical training there is a lack of simulation based activities including procedural labs. Suturing is a critical skill for trainees to master in the emergency department. However, supervised practice is needed prior to suturing a real patient for the first time. This innovation allows early trainees to master suturing while on shift, using easy to find materials, which increases procedural competency and confidence. This activity allows the teacher to assess and correct the trainees procedural skills prior to attempting to suture a real patient.

Name of innovation

  • This Do-It-Yourself Suture Kit Station incorporates easy to find materials available in every emergency department, allowing early trainees to master suturing prior to suturing real patients.

Learners targeted

  • Medical students and early trainees who need suture practice

General group size

  • One-on-one student training is ideal, but can have multiple students who can practice using multiple suturing stations
  • If teacher unable to instruct while on shift, trainees can be shown a suture training video and practice alongside the video

DIY suture training kit for laceration repair

Materials needed

  • Blue chuck pad
  • Paper/cloth tape
  • Scalpel
  • Suture material
  • Suture kit

More detailed description of the activity and how it was run

  • Make the DIY Suture Kit Station (see above video):
    • Place a thick chuck pad on a flat sturdy surface.
    • Apply cloth tape to the entire surface of the chuck, and tape over the chuck. This is now the suturing pad.
    • Use a scalpel to make an incision to the pad.
    • Use the back blunt end of the scalpel to ‘fluff’ up incision edges to make laceration.
  • Use a laceration repair kit and suture to close the laceration.
  • Instruct the trainee on proper suturing technique on the suture station (or show a suture training video)
  • Have the trainee continue practicing until adequate comfort and proficiency level is achieved
  • Suture real patient!

Lessons learned, especially with regard to increasing resident and program buy in

  • Procedural skills require much repetition to gain proficiency. This is best done with video tutorials, supervision, and deliberate practice.
  • Practicing in a simulated environment greatly improves skill and confidence in real clinical practice.

Educational theory behind the innovation including specifics/styles of teaching involved

  • Simulation practice increases procedural competency.
  • Practicing on shift allows trainees to reach the number of repetitions required to gain mastery in suturing, Routt [1] showed that the number of repetitions required to gain proficiency was 41 times.
  • Competency in suturing is required even when cases are low. Wongkietachorn et al. demonstrated that tutoring suturing improves the trainees’ skillset. A practice suture kit helps improve retention for real-life scenarios [2].

Pearls

  • This DIY suture pad station technique is easily available and inexpensive.
  • To improve suturing techniques and enhance skill retention, medical students and early trainees need to learn with guided supervision on simulated task trainers.

 

References

  1. Routt E, Mansouri Y, de Moll EH, Bernstein DM, Bernardo SG, Levitt J. Teaching the Simple Suture to Medical Students for Long-term Retention of Skill. JAMA Dermatol. 2015 Jul;151(7):761-5. doi: 10.1001/jamadermatol.2015.118. PMID: 25785695.
  2. Wongkietkachorn A, Rhunsiri P, Boonyawong P, Lawanprasert A, Tantiphlachiva K. Tutoring Trainees to Suture: An Alternative Method for Learning How to Suture and a Way to Compensate for a Lack of Suturing Cases. J Surg Educ. 2016 May-Jun;73(3):524-8. doi: 10.1016/j.jsurg.2015.12.004. Epub 2016 Feb 20. PMID: 26907573.
By |2021-10-08T10:19:05-07:00Oct 15, 2021|IDEA series, Trauma|

EMRad: Can’t Miss Adult Traumatic Hip and Pelvis Injuries

 

Have you ever been working a shift at 3 AM and wondered, “Am I missing something? I’ll just splint and instruct the patient to follow up with their PCP in 1 week.” This is a reasonable approach, especially if you’re concerned there could be a fracture. But we can do better. Enter the “Can’t Miss” series: a series organized by body part that will help identify injuries that ideally should not be missed. This list is not meant to be a comprehensive review of each body part, but rather to highlight and improve your sensitivity for these potentially catastrophic injuries. We’ve already covered the adult elbow, wrist, shoulder, ankle/foot, and knee. Now: the hip.

 

(more…)

By |2021-09-01T17:23:13-07:00Sep 3, 2021|Orthopedic, Radiology, SplintER, Trauma|
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