Case Report(s)
Meghan Martin
PGY 5
ECMC Survivor
First Case
• 50yo female presents by EMS. The call was for
shortness of breath/asthma exacerbation. On
EMS arrival, patient was in distress, and very
tight and lethargic. Very quickly, the patient
stopped breathing and had cardiac arrest. CPR
immediately initiated, patient given Epi x3,
albuterol and IVF bolus with ROSC. Brought to
ECMC.
First Case
• On arrival, patient remained tight and was
intubated with Etomidate and Succinylcholine.
• CXR, CT head and CT chest obtained.
• CT chest showed small bilateral
pneumothoraxes.
• Patient on ventilator, so MICU requests
bilateral pigtails placed.
First Case
• A ER intern and PEM fellow are eager to place
the pigtails under the guidance of a well
respected and capable third year ER resident.
• Patient of large habitus (unpalpable
landmarks) and there is significant difficulty
bilaterally feeding the guide wire.
• Attending assists on the right side and pigtail
secured in suboptimal position.
First Case
• Left side tube placed in more optimal location,
but when inner dilator is removed, patient has
active bleeding through the tube. Dilator is
replaced.
• Chest x-ray obtained.
• Cardiothoracic surgery paged stat.
First Case
• CT Surgery evaluates patient and reviews CXR.
• Tube is in good position. Bleeding is NOT
arterial.
• Advised us to remove dilator and hook up to
suction. Lung should re-expand and
tamponade bleeding. Obtain repeat CXR.
Outcome
• Chest tube puts out about 40cc of blood, then
stops. Repeat CXR is perfect.
• Patient moved to MICU and both tubes
removed in 3 days.
• Reason for patient’s cardiac arrest is never
clearly identified.
• Patient neurologically devastated, never
regains any function.
That’s why Peds is better
Case Two
• EMS notification about 14yo male with GSW
to chest. No further information available.
• Priority 1 notification. Surgery prepares chest
tube set up.
• Everyone gowned and ready.
Case Two
• On arrival, patient is pale appearing,
uncooperative, swearing. Received one liter
NS and 1 unit PRBCs en route.
• EMS reports BP initially in 60’s, responded
well to volume.
Case Two
• BP 93/55 HR 120 Sats 90-93% on NRB
• GSW to left upper chest (4th intercostal
space), exit wound just below scapula.
Decreased BS on left.
• Primary survey completed, got off backboard.
• Initial CXR obtained
Case Two
• Surgery immediately places chest tube in left
chest.
• No reported difficulty?
• Drains 400cc blood
• Repeat CXR and CT chest performed.
Case Two
• Surgical Senior resident is publically
humiliated by his attending.
• Tube is pulled back into adequate location.
• Draining well.
Case Two
• Further questioning of patient and family,
patient says he was cleaning the gun,
accidently went off.
• EMS reports questionable text messages on
patient’s phone, concerning for suicide
attempt.
• Family extremely upset, unable to consider
suicide as potential
• No cleaning supplies at the scene.
Lesson of the Day!
• If the injury doesn’t kill you, the chest tube
might!!
Chest Tube Placement