Needle Thoracocentesis Research Articles

Do Bilateral Pleural Effusions Always Have the Same Cause?

A 67-year-old man with a history of seropositive rheumatoid arthritis (RA) was admitted to the Internal Medicine ward for bilateral pleural effusion. Two years before this episode, coinciding with an exacerbation of the RA, he was incidentally diagnosed with asymptomatic left pleural effusion compatible with rheumatoid exudate, which was resolved with a tube thoracostomy. Three weeks before admission, the patient developed asthenia, orthopnoea and progressive dyspnoea. A chest x-ray revealed bilateral pleural effusion occupying the lower third of the left hemithorax and a smaller portion of the right hemithorax along with marked elevation of N-terminal fragment of pro-brain natriuretic peptide levels. The patient was admitted with a diagnosis of left-sided heart failure. Transthoracic echocardiography and cardiac catheterization confirmed the existence of ischaemic cardiomyopathy. After 2 days of diuretic treatment, the right pleural effusion resolved, but the left effusion persisted. A needle thoracentesis was performed, draining 800 ml of milky fluid compatible with rheumatoid pseudochylothorax.LEARNING POINTSBilateral pleural effusions nearly always have the same cause, and usually thoracentesis on only one side is needed.Rarely, however, there can be two separate causes: this is known as Contarini’s syndrome.

Use of Telemedicine to Improve Neonatal Resuscitation.

Most newborn infants do well at birth; however, some require immediate attention by a team with advanced resuscitation skills. Providers at rural or community hospitals do not have as much opportunity for practice of their resuscitation skills as providers at larger centers and are, therefore, often unable to provide the high level of care needed in an emergency. Education through telemedicine can bring additional training opportunities to these rural sites in a low-resource model in order to better prepare them for advanced neonatal resuscitation. Telemedicine also offers the opportunity to immediately bring a more experienced team to newborns to provide support or even lead the resuscitation. Telemedicine can also be used to train and assist in the performance of emergent procedures occasionally required during a neonatal resuscitation including airway management, needle thoracentesis, and umbilical line placement. Telemedicine can provide unique opportunities to significantly increase the quality of neonatal resuscitation and stabilization in rural or community hospitals.

Rubrum Coelis: The Contribution of Real-Time Telementoring in Acute Trauma Scenarios-A Randomized Controlled Trial.

Background: Most deaths in military trauma occur soon after wounding, and demand immediate on scene interventions. Although hemorrhage predominates as the cause of potentially preventable death, airway obstruction and tension pneumothorax are also frequent. First responders caring for casualties in operational settings often have limited clinical experience.Introduction: We hypothesized that communications technologies allowing for real-time communications with a senior medically experienced provider might assist in the efficacy of first responding to catastrophic trauma.Methods: Thirty-three basic life saving (BLS) medics were randomized into two groups: either receiving telementoring support (TMS, n = 17) or no telementoring support (NTMS, n = 16) during the diagnosis and resuscitation of a simulated critical battlefield casualty. In addition to basic life support, all medics were required to perform a procedure needle thoracentesis (not performed by BLS medics in Israel) for the first time. TMS was performed by physicians through an internet link. Performance was assessed during the simulation and later on review of videos.Results: The TMS group was significantly more successful in diagnosing (82.35% vs. 56.25%, p = 0.003) and treating pneumothorax (52.94% vs. 37.5%, p = 0.035). However, needle thoracentesis time was slightly longer for the TMS group versus the NTMS group (1:24 ± 1:00 vs. 0:49 ± 0:21 minu, respectively (p = 0.016). Complete treatment time was 12:56 ± 2:58 min for the TMS group, versus 9:33 ± 3:17 min for the NTMS group (p = 0.003).Conclusions: Remote telementoring of basic life support performed by military medics significantly improved the medics' ability to perform an unfamiliar lifesaving procedure at the cost of prolonging time needed to provide care. Future studies must refine the indications and contraindications for using telemedical support.

Abstract 5011: Patient-derived organotypic cancer spheroids (PDOCS) as predictive models for the treatment of cancer in a clinically meaningful time frame

Abstract Background: Standard two-dimensional cell cultures do not retain the key characteristics of the human cancers from which they are derived and treatment effects are not always able to be replicated in vivo, making the development of alternative culturing systems paramount. Specifically, commercially available cell lines do not fully represent the mutation profiles seen in human cancers. Here we investigate the feasibility of three-dimensional PDOCS to more accurately represent the cancers from which they are derived and to predict treatment sensitivity in a clinically meaningful time frame. Methods: Surgical resection, core needle biopsies, paracentesis or thoracentesis samples from patients with various types of cancer were obtained under an approved IRB protocol, digested and spheroid cultures grown suspended in Matrigel. PDOCS were grown for up to two weeks and passaged at least once prior to treatment. PDOCS were imaged using brightfield imaging (4X) prior to treatment with vehicle or 5-fluorouracil (5-FU; 1, 10, or 100 µM) and/or radiation (2 or 5 Gy). After 2 days of treatment, the 5-FU was removed and the cultures were allowed to grow for an additional 2 days. PDOCS were re-imaged and the relative change in diameter was calculated using ImageJ software and compared to untreated controls. Optical metabolic imaging (OMI) was performed with a multiphoton microscope to probe the fluorescence lifetime and optical redox ratio of metabolic co-enzymes NAD(P)H and FAD. Single-cell analysis of each image was completed using Cell Profiler software to parse resistant cell populations in each PDOCS sample tested. DNA for mutation profile analysis was isolated and sequenced using a QIAseq targeted panel. Results: PDOCS were successfully isolated from a variety of cancers including colorectal (CRC), pancreas, lung, neuroendocrine, liver, breast, and ovarian. Key phenotypic characteristics of the tumors were retained in PDOCS cultured including crypt-like structures, mucin production and Ki67 proliferation rates. Cancer hot spot sequencing was performed comparing PDOCS and the tumors from which they were derived. Over 90% of the nonsynonymous mutations were identical, except in the setting of microsatellite instability. All driver mutations were identical (i.e., APC, KRAS, PIK3CA, TP53). Differential sensitivity to chemoradiation was observed among 4 different colorectal PDOCS treated with 5-FU and radiation (Median % PDOCS diameter change vs control: Patient A 17.1, p=0.64; Patient B -3.05, p=0.02; Patient C -19.4, p=2x10-5; Patient D -31.3, p=0.002). Similar response data were determined using OMI; however, single-cell analyses identified potentially resistant cell populations. Conclusions: PDOCS retain key characteristics of the cancers from which they are derived and can be utilized for treatment sensitivity testing in a clinically meaningful time frame. Citation Format: Cheri A. Pasch, Peter F. Favreau, Alex E. Yueh, Kwang P. Nickel, Christopher P. Babiarz, Philip B. Emmerich, Rosabella T. Pitera, Susan N. Payne, Demetra P. Korkos, Joseph T. Sharick, Carley M. Sprackling, Linda Clipson, Kristina A. Matkowskyj, Michael A. Newton, Melissa C. Skala, Michael F. Bassetti, Randall J. Kimple, Dustin A. Deming. Patient-derived organotypic cancer spheroids (PDOCS) as predictive models for the treatment of cancer in a clinically meaningful time frame [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5011.

Simulathon - Pediatric trauma simulation training in-situ across India

Background : Simulation training workshops conducted by PediSTARS (Pediatric Society for Training and Research in simulation) India over the last year identified a gap in the knowledge of having a structured approach to assessment of pediatric trauma. PediSTARS organised a nationwide pediatric trauma simulathon on world trauma day to encourage the simulation trainers across the country to conduct in-situ pediatric simulation training. Methods : Simulation trainers across the country trained through PediSTARS Training or Trainers workshop were approached via email and WhatsApp group. All the interested simulation trainers were sent a trauma scenario which could be modified to local training needs. All centres conducted the training session on world trauma day- October 17th, 2016 and shared their experiences and photos of the session on the WhatsApp group. An online survey to collate the experience was sent to all the simulation trainers. Results : 20 centres across India participated in the Simulathon. The target audience varied from Emergency nurses and doctors, paediatricians, under graduate and post graduate students, and parents. All centres uniformly identified gaps in knowledge of initial assessment and primary survey of pediatric trauma, skills such as needle thoracocentesis and team leadership. All centres uniformly reported 100% acceptance of simulation based training and the need to have more such training sessions locally to enhance their learning experience. The challenges described by the simulation trainers include time and equipment constraints for regular simulation training locally. Conclusion : Pediatric trauma training is a much needed and wanted aspect of training that can be addressed via simulation in-situ successfully. A thematic approach such as a simulathon can encourage trainers to conduct sessions more regularly.

Failure rate of prehospital chest decompression after severe thoracic trauma

IntroductionChest decompression can be performed by different techniques, like needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT).The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effectiveness of these techniques. Material and methodsIn this retrospective case series study, all medical records of adult trauma patients undergoing prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied. ResultsIn a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen patients had NT, six patients TT, one patient NT as well as TT, and no patients had LT.Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT related complications were reported during hospitalization. ConclusionPrehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission.

Development of pulmonary air leak in an extremely-low-birth-weight infant without mechanical ventilation: a case report.

A 34-year-old woman at 25 weeks 3 days was diagnosed with preterm labor and underwent an emergency cesarean section. The neonate did not cry or show any activity. The heart rate was 80 beats/min and the oxygen saturation on pulse oximetry (SpO2) was 77%. Immediately, positive pressure ventilation was delivered by T piece resuscitator, and then anesthesiologist performed endotracheal intubation. The neonate demonstrated severe cyanosis and the SpO2 dropped to 30%. Ventilation was not successful even after intubation, and we found neck crepitus, chest wall distension, and severe cyanosis on physical examination. We suspected tension pneumothorax and performed needle thoracentesis. The neonate was stabilized and transferred to the neonatal intensive care unit for further treatment, but expired on the 10th day of life. We report a case of pulmonary air leak developing tension pneumothorax, pneumomediastinum, subcutaneous emphysema in an extremely-low-birth-weight preterm infant immediately after birth.

ULTRASOUND MEASUREMENT OF CHEST WALL THICKNESS IN ELITE RUGBY PLAYERS; A COMPARISON BETWEEN THE NEEDLE THORACOCENTESIS SITES

AimsThere are no known published studies to support current pitch side guidelines for the management of a tension pneumothorax in a sporting population (1). Temporary management of this condition involves...

Comparison of Indwelling Pleural Catheters to Serial Thoracentesis in Management of Refractory Pleural Effusions Secondary to Congestive Heart Failure

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Patients with chronic congestive heart failure (CHF) often present with pleural effusions causing dyspnea and worsening hypoxemia. Patients who fail medical therapy often need thoracentesis and recurrent admissions for symptom control. Use of indwelling pleural catheters (IPC) for malignant recurring effusions has been shown to improve quality of life; though there is limited data regarding its use in CHF. We evaluated management outcomes of pleural effusions secondary to CHF, refractory to optimal medical regimen; with either an IPC or serial thoracentesis METHODS: A retrospective study (January 2014 to October 2015) was conducted comparing management outcomes of all patients with refractory transudative pleural effusion secondary to CHF admitted to Northside medical center, who required an IPC, thoracentesis or both. Comparisons were made with regards to; length of hospital stay, number of readmissions related to pleural effusion, number of interventions or procedures and complications related to either method. RESULTS: We identified 24 patients (12 (50%) males and 12 (50%) females) with a mean age of 77.6 years. 8 had systolic CHF, 22 had diastolic CHF and 7 were noted to have renal dysfunction. 13 patients (54.2%) required repeated thoracentesis initially followed by IPC insertion; 10 patients (41.7%) were treated with serial thoracentesis alone and 1 patient (4.2%) had IPC inserted at presentation, following failure of outpatient management. A total of 90 interventions (with needle thoracentesis) were performed in 23 patients (average 3.91) and 25 IPCs were inserted in 14 patients. When comparing, the serial thoracentesis group to the IPC group; the mean length of hospital stay in the thoracentesis group was 17.39 days as compared to 8.36 days in the IPC group (the mean difference was 9.03 days, 95% CI, 2.36-15.71 and a P value of 0.0094). Patients requiring thoracentesis were admitted on average three times at a rate of once every 28 days in comparison to once the in the IPC group, which was mainly for IPC removal (mean difference was 1.58 admissions, 95% CI, 0.67-2.50 and p value of 0.0012). No mortality was reported from procedure in either group; however, 1 patient in each group developed pneumothorax from the procedure. 1 patient with an IPC developed empyema that required pleurodesis. Ten patients among the IPC group (71.4%) achieved successful spontaneous pleurodesis without any complications. CONCLUSIONS: Indwelling Pleural Catheters reduce the length of hospital stay and rate of readmissions when compared to serial thoracentesis, in the treatment of refractory recurrent pleural effusion secondary to CHF. Risks of infection are justified and further studies are needed to assess its utility in management of benign pleural effusions. CLINICAL IMPLICATIONS: Minimal options are available for CHF patients with recurrent pleural effusions despite optimal medical therapy. Not many patients are good candidates for surgical interventions and further research is needed to look into less invasive management strategies. Chemical pleurodesis as reported in the past had disappointing results with increased morbidity. Placement of an indwelling pleural catheter can prevent re-admissions and repeated interventions; hence improving quality of life. DISCLOSURE: The following authors have nothing to disclose: Tamer Said Ahmed, Ahmed El-Moghraby, Nafsi Tabassum No Product/Research Disclosure Information

Techniques of training in the management of tension pneumothorax: bridging the gap between confidence and competence.

Thoracocentesis is a simple procedure with high potential to be life-saving, but is associated with complications if performed incorrectly. The aim of this study was to determine both the ability and confidence of practitioners who would be expected deal with a tension pneumothorax both in and out of hospital. If any shortfall was identified between theoretical and practical knowledge the goal was to develop techniques to overcome that shortfall. A total of 51 consenting medical practitioners were recruited to participate in a prospective single-subject crossover applied behavioural analysis study. The primary outcome was the change in accuracy of identification of the correct site for needle thoracocentesis on an anatomical diagram and by verbal description. This was compared before and after the introduction of brief and frequent "life-saving practical skills" training sessions. Participants' confidence was also assessed pre and post intervention. There was a disparity pre-intervention between confidence (79.4% felt able to perform the procedure without assistance) and competence (85.2% of these incorrectly identified the anatomical site). Following intervention, the in-practice correct identification of the site increased from 15.7% to 52.9%. The disparity between confidence and competence still existed by was reduced. The learning and re-learning of this skill should occur regularly through both theoretical and practical teaching to ensure the adequate ability of practitioners and reduce the danger associated with false confidence.

A Rare Complication of Cardiopulmonary Resuscitation: Tension Pneumothorax

Chest compressions during cardiopulmonary resuscitation (CPR) can be traumatic. We report a rare complication of CPR in which the patient experienced 2 rib fractures associated with tension pneumothorax. An 83 year-old man with a history of chronic obstructive pulmonary disease (COPD) and chronic renal disease was accepted with respiratory insufficiency. In a few minutes, he developed hypotension, bradycardia, and hypoxia. As a consequence of cardiac arrest, basic life support was performed. It was realized that the left side of the chest had little movement while the right side was hyperexpanded. Chest radiograph showed a right sided pneumothorax. A 14G intravenous cannula was inserted through the second right intercostal space in the mid-clavicular line. Afterwards an intercostal tube was inserted in the same place. Nevertheless, the patient died approximately 30 hours after admission. Tension pneumothorax is a well known complication of intermittent-positive-pressure ventilation (IPPV) and chronic lung disease. Tension pneumothorax may be difficult to diagnose and therefore, maybe missed during a complex resuscitation attempt. Since diagnosis is difficult during ongoing resuscitation, either a chest tube or intercostal cutdown can be considered following needle thoracocentesis to exclude tension pneumothorax as a probable cause of refractory cardiac arrest in high-risk patients.

Diagnostic utility of medical thoracoscopy in peripheral parenchymal pulmonary lesions

IntroductionVisceral pleural biopsy and peripheral lung biopsy can be undertaken at the same time as parietal pleural biopsy during medical thoracoscopy, with or without coexistence of a pleural effusion with lung disease. ObjectiveTo assess the accuracy and safety of medical thoracoscopy for the evaluation of peripheral parenchymal pulmonary lesions. PatientsWe studied 15 patients with peripheral parenchymal pulmonary disease, the cause of which had not been determined after initial investigations, including needle biopsy and thoracocentesis if pleural effusion is present. Two patients have solitary peripheral lesions while thirteen have diffuse pathology. Seven patients have pleural effusion in addition to parenchymal lesions. MethodsOnly one patient had thoracoscopy under general anaesthesia while the remaining fourteen were given local anaesthesia with mild sedation. Visually directed biopsies were taken from the lung using electrocautery in all patients. Biopsies were taken also from the parietal pleura in only seven patients. MeasurementsWe recorded clinical characteristics, laboratory data, findings and duration of thoracoscopy, and any complications associated with the procedure. ResultsA definitive diagnosis was established in 12 patients: 4 patients had primary bronchogenic carcinoma while 5 patients had metastases. Only 3 patients had benign parenchymal disease. Overall, thoracoscopy had a sensitivity of 80% for the diagnosis of peripheral parenchymal pulmonary lesions. Thoracoscopy was well tolerated under local anaesthesia and entailed hospitalization for less than 48h in most cases. No deaths occurred, although 6.7% of patients had major complications, and 20% had minor complications. ConclusionsAmong patients with peripheral parenchymal pulmonary lesions remaining undiagnosed after usual initial investigation and even transthoracic needle biopsies, thoracoscopy done under local anaesthesia is a rapid, safe, and well-tolerated procedure with an excellent diagnostic yield that is equivalent to that of thoracotomy.

Sufficient catheter length for pneumothorax needle decompression: a meta-analysis.

Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis. A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness. The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm. A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence.

G139(P) Advanced neonatal emergencies: confidence and experience levels of new registrars

Aims Paediatric trainees, who step up to the role of registrars at ST4/5 levels, are required to be competent in neonatal emergencies. Some of the competencies as highlighted by the RCPCH curriculum for level 2 are: Ability to lead initial and advanced resuscitation when required Ability to intubate pre-term babies without supervision Understanding of the principles and ability to initiate mechanical ventilation Ability to perform needle thoracocentesis for management of pneumothorax These factors are especially important out of hours, when Consultants are non-resident. The aim of this project is to establish the current level of knowledge and skill set of ST4/5 trainees in the South West region. This information was acquired as part of the process to set up advanced neonatal simulation training within the region. Methods A 10 questions survey was sent to the ST4/5 paediatric trainees in the South West region. To improve number of responses, the survey was sent through the respective deaneries and posted on the region’s paediatric social media page. The survey was carried out for a period of 45 days (October to November 2014). Results Responses were obtained from 12 trainees (ST4:7, ST5:5) and the key results are listed below: Confidence in mechanical ventilation strategies: Only 41% of trainees stated that they were confident, with the rest either having confidence only with Consultant support or not confident. 50% of trainees have intubated 83% of trainees have never performed emergency needle thoracocentesis independently. 91% of trainees have never led an advanced resuscitation leading to withdrawal of care on the resuscitaire. 100% of trainees agreed that simulation training on advanced neonatal emergencies would add value to their skills and knowledge. Conclusion New paediatric registrars are expected to be competent in advanced neonatal emergencies and procedures. Despite this, a high proportions in the survey lack experience and confidence in independent management and procedural skills for such scenarios. Training through neonatal simulation is vital to address these training needs.

Answer to Image of the Month

Journal of Paediatrics and Child HealthVolume 50, Issue 10 p. 842-842 Letter to the EditorFree Access Answer to Image of the Month First published: 06 October 2014 https://doi.org/10.1111/jpc.12560_2AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat This infant had a tension pneumothorax confirmed on positive transillumination (Fig. ). The Wee Sight is a cold light device available to help transilluminate blood vessels for cannulation. His pneumothorax was aspirated via needle thoraco-centesis and chest drain inserted. He was successfully extubated to continuous positive airway pressure (C-PAP) at day 23 without further pneumothorax. Tension pneumothorax is relatively rare in very low birthweight infants (9%) with a predominance in male infants. Transillumination has been described as being useful in the diagnosis of pneumothorax.1 Our case provides a good example of this. Reference 1Kuhns LR, Bednarek FJ, Wyman ML et al. Diagnosis of pneumothorax or pneumomediastinum in the neonate by transillumination. Pediatrics 1975; 56: 355– 360. Volume50, Issue10October 2014Pages 842-842 ReferencesRelatedInformation

PC.65 A tale of pigtails – Audit on the outcome and efficacy of pigtail catheters

AimsTo study the outcome of all pigtail chest drain insertions to treat pneumothorax on our NNUTo study the efficacy of different sizes of pigtail chest drains.MethodsAudit of all babies who...

Board 522 - Technology Innovations Abstract Multi-Purpose Use of a Novel Gel Protected Insert for Neonatal High Fidelity Simulation and for “Fluid Removal” Task Trainers. (Submission #1147)

Introduction/Background Introduction: Diagnostic and therapeutic procedures such as removal of pleural, pericardial and peritoneal fluid with needle Thoracentesis, Pericardiocentesis and Paracentesis, respectively are essential to fellowship training across all critical care specialties. Opportunities to perform the mentioned critical and lifesaving procedures and partake in complex resuscitations are diminishing during Neonatal Fellowship training. Task Trainers and Simulation would offer an avenue for exposure and development of expertise, but current Neonatal High Fidelity (HF) simulators and task trainers are not designed to allow practice of the above mentioned invasive “fluid removal” procedures. We have developed a highly economical gel protected insert that can not only be adapted in a Low Fidelity Manikin with the purpose of using as a task trainer; but also in High Fidelity Manikins for the purposes of bringing realism of ’fluid removal’ during complex scenarios such as Hydrops and Cardiac Tamponade . The advantage of our set up in comparison to fluid filled latex balloons that have been described previously1 is that our gel protected insert has a conduit for refilling fluid and hence can be used multiple times as a task trainer; and there is very limited opportunity for fluid leakage thus protecting the electronic circuits of high fidelity manikins. Methods Methods: 1) A four inch bladder bag was created using flock backed Vinyl fabric and plastic. A Foley tube was inserted during the bladder bag construction that serves as conduit for re-filling fluid into the bladder; 2) Plastic strips were secured using an Armadillo approach (for flexibility) on one side of the insides of the bladder to provide stick point resistance; 3) Additional foam protection was provided at junction points and synthetic ballistic gel was used to cover all sides; 4) The edges were trimmed to desired shape/size and inserted in to the ‘ U ’ shaped gel based insert that can be placed on a High Fidelity manikin such as the SimNewB, covered it with additional artificial skin and created a safe, realistic hydrops fetalis model for repeated use during simulations. Results: Conclusion Conclusions: We present an effective and economical synthetic gel protected insert that can be used with both low fidelity manikins to develop task trainers and with existing high fidelity manikins to provide realistic experience for fellows and residents for invasive procedures such as Paracentesis, Thoracentesis, Suprapubic Aspiration and Pericardiocentesis. The use of this gel insert will not be limited to neonatal use as invasive ’fluid removal’ procedures are performed across all critical care specialties.

G23(P) Education and Training Using an Innovatively Adapted Manikin: Simple, Affordable, Feasible and Effective (SAFE)

IntroductionHi-fidelity manikins are often used in simulation courses. However they are very expensive and some of the skills like drainage of pneumothorax or insertion of chest-drains/rectal probes cannot be demonstrated...

Needle Thoracentesis Decompression: Observations From Postmortem Computed Tomography and Autopsy

Needle thoracentesis decompression (NTD) is a recommended emergency treatment for tension pneumothorax. Current doctrine recognizes two suitable sites: the second intercostal space in the midclavicular line and the fourth or fifth intercostal space in the anterior axillary line.A review was conducted of postmortem computed tomography and autopsy results in 16 cases where NTD was performed as an emergency procedure.In 16 cases with 23 attempted procedures, the outcome was confirmed in 17 attempts. In 7 placements, the catheter was in the pleural cavity; in 7 placements, the catheter never entered the pleural cavity; and in 3 placements, cavity penetration was verified at autopsy even though the catheter was no longer in the cavity. Success was noted in 6 of 13 anterior attempts and 4 of 4 lateral attempts, for an overall success rate of 59% (10 of 17). In the remaining 6 attempted procedures, a catheter was noted in the soft tissue on imaging; however, presence or absence of pleural cavity penetration was equivocal. All placements were attempted in the combat environment; no information is available about specifically where or by whom.NTD via a lateral approach was more successful than that via an anterior approach, although it was used in fewer cases. This supports the revision of the Tactical Combat Casualty Care Guidelines specifying the lateral approach as an alternative to an anterior approach.

The Importance of a Satisfactory Biopsy for the Diagnosis of Lung Cancer in the Era of Personalized Treatment

Advances in molecular biology are improving the understanding of lung cancer and changing the approach to treatment. A satisfactory biopsy that allows for histologic characterization and mutation analysis is becoming increasingly important. Most patients with lung cancer are diagnosed at an advanced stage, and diagnosis is often based on a small biopsy or cytology specimen. Here, we review the techniques available for making a diagnosis of lung cancer, including bronchoscopy, ultrasound-guided bronchoscopy, mediastinoscopy, transthoracic needle aspiration, thoracentesis, and medical thoracoscopy. We also discuss the indications, complications, and tissue yields of those techniques, especially as they pertain to testing for molecular markers.