CA | MEDSURG

II. Chest Tube Placement

Indications: pneumothorax, fluid in the chest, prophylaxis for high risk patients (rib fx, penetrating

trauma, positive pressure ventilation)

Technique:

place the patient in the supine position

prep the skin with providine-iodine solution and drape operative site

measure the chest tube from the desired entrance site to the apex of the chest.

anesthetize the skin with lidocaine using a 25-gague needle. Anesthetize the deeper tissues with a

20-gague needle. The pleura should be infiltrated with liodocaine.

incise the skin one interspace below the desired site of insertion.

create a subcutaneous tunnel with a Kelly clamp over the rib above the incision.

enter the pleural space immediately above this rib with the tip of the clamp and open the clamp,

spreading the pleura

insert a finger into the hole and confirm that the space is free of adhesions

grasp the tip of the thoracostomy tube with the Kelly clamp and insert both into the pleural space

direct the tube superiorly and posteriorly for drainage of hemothorax or hydrothorax and anterior

for pneumothorax

ensure that the last hole in the tube is within the thoracic cavity and secure the tube to the skin

with a suture.

cover with a sterile dressing and connect to the drainage system

Complications: hemorrhage, infection, lung laceration, cardiac injury, subcutaneous placement,

pulmonary edema, intraperitoneal tube placeme

\\\\\\\\\\\\\
Typhoid fever is an illness caused by the bacterium Salmonella Typhi (S. Typhi). It
infects your small intestines (gut) and causes high fever, stomach pain and other
symptoms. Typhoid fever is also called enteric fever.
Paratyphoid fever is similar to typhoid with more mild symptoms. It’s caused by Salmonella Paratyphi (S.
Paratyphi).

S. Typhi and S. Paratyphi are different than the Salmonella bacteria that cause salmonellosis, a common
type of food poisoning.

Who does typhoid fever affect?

Typhoid fever is most common in rural areas of developing countries where there isn’t modern
sanitation. Countries in South and Southeast Asia, Central and South America, Africa and the Caribbean
are most affected by typhoid. Travelers are most at risk when visiting Pakistan, India or Bangladesh.

Children are more likely to get typhoid than adults.

What’s a long-term carrier of typhoid fever?

Some people continue to be contagious with typhoid fever even after they’ve recovered
(long-term carrier). You can spread typhoid for a year or more with no symptoms. It’s
important to get tested for S. Typhi after you feel better to make sure you can’t spread it
to other people.

What’s the difference between typhoid and typhus?

While the names sound the same, typhoid and typhus are different illnesses, caused by
different bacteria. The symptoms are similar — so much so that doctors used to think
they were the same illness. We now know they’re different illnesses, but the similar
name stuck (and so did the confusion it causes).

Symptoms and Causes

What are the symptoms of typhoid fever?

Typhoid fever gets its name from a high fever that can last for weeks if left untreated. It
often gets progressively worse over a few days.

Other symptoms of typhoid fever include:

• Headache.
• Chills.
• Loss of appetite.
• Stomach (abdominal) pain.
• “Rose spots” rash, or faint pink spots, usually on your chest or stomach.
• Cough.
 • Muscle aches.
• Nausea, vomiting.
• Diarrhea or constipation.

What causes typhoid fever?

Typhoid fever is caused by the bacterium S. Typhi. It lives in the gut (intestines) of
infected people and can contaminate food and water.

How does typhoid fever spread?

Typhoid fever usually spreads through food or water contaminated with S. Typhi. This
can happen if someone with typhoid touches something you eat or drink without
washing their hands. It can also happen if waste water (water that has poop or pee in it)
gets into water you drink or on food you eat.

You can get typhoid from another person if they don’t wash their hands after going to
the bathroom. When they touch surfaces and objects (like phones or doorknobs) they
can leave bacteria behind that can transfer to the next person who touches it.

What are the stages of typhoid fever?

You can develop symptoms of typhoid fever gradually in four stages. Early treatment with antibiotics can
keep you from progressing to later stages.

• Stage 1. You can start getting typhoid symptoms anywhere from five to 14 days after coming in
contact with S. Typhi. The first symptom is a fever that gets higher over a few days — called
“stepwise” since it goes up in steps. The bacteria is moving into your blood in this stage.
• Stage 2. Around the second week of fever, the bacteria is multiplying in your Peyer’s patches
(part of your immune system that identifies harmful invaders). You’ll start experiencing
abdominal pain and other stomach symptoms, like diarrhea or constipation. You might get “rose
spots,” small pink dots on your skin that look like a rash.
• Stage 3. If not treated with antibiotics, the bacteria can cause severe damage, usually around
the third week after your symptoms start. Some people get serious complications, like internal
bleeding and encephalitis (inflammation in your brain).
• Stage 4. Stage four is when most people begin to recover. Your high fever begins to come down.
S. Typhi can live in your gallbladder without causing symptoms, which means you may still be
contagious even after you feel better.

Diagnosis and Tests

Your healthcare provider will take samples of body fluids or tissue to test for signs of S. Typhi. They
might take samples of your:
 • Blood. Your provider will use a needle to take a small tube of blood from your arm.
• Poop (stool). Your healthcare provider will give you a sterile container and instructions on how
to collect a sample.
• Pee (urine). You may be asked to pee into a cup given to you by your healthcare provider.
• Your provider might numb your skin and take a sample with a small razor or scalpel.
• Bone marrow. Your provider will numb your skin and use a special needle to get a sample of the
inside of your bones. It’s rare that you’d ever need this test for diagnosis.
• You provider may also take X-rays (pictures of the inside of your body) to look for changes in
your lungs.

Management and Treatment

Typhoid is treated with antibiotics. Some newer types of the bacteria are able to survive antibiotic
treatments, so you’ll be treated with different antibiotics depending on what type of typhoid you have
and where you got sick. Paratyphoid fever is also treated with antibiotics.

What medications are used to treat typhoid fever?

Your healthcare provider will treat typhoid fever with antibiotics, which may include:

• Ciprofloxacin, levoflaxin or ofloxacin.

• Ceftriaxone, cefotaxime or cefixime.
• Azithromycin.
• Carbapenems.
• If your case is severe, you may be treated with steroids, like dexamethasone.
• Antibiotic resistance in typhoid

Bacteria like S. Typhi can sometimes develop resistance to medications. This means that antibiotics
don’t work to destroy them anymore (antibiotic resistance).

Many cases of typhoid can’t be destroyed by antibiotics we once used, but some drugs still work on
them. Some are extremely drug resistant (XDR typhoid) and only a few antibiotics still work on them.
This is one of the reasons that getting vaccinated to prevent typhoid is so important.