Diagnostic punctures

Thoracentesis

According to clinical guidelines, pleural puncture is indicated for an ambiguous clinical picture when there is a well-founded suspicion of hemothorax or pneumothorax. Performing the procedure requires a strict selection of anatomical points:

• In the second intercostal space along the midclavicular line.
• In the sixth or seventh intercostal space along the posterior axillary line.

The exudate obtained during the manipulation must be sent for hematological and bacteriological examination. This is necessary to accurately assess ongoing bleeding and determine the activity of the inflammatory process. Thoracentesis is often concluded by placing a pleural cavity drainage tube.

It is strictly not recommended to perform a diagnostic puncture in the absence of objective signs of fluid accumulation (hydro-, chyl-, hemothorax) or air (pneumothorax). Under such conditions, the risk of iatrogenic injuries becomes maximal. In addition, it is forbidden to puncture and drain the cavity in closed chest trauma without prior visualization of the contents. A blind puncture can lead to diaphragmatic injury with the retrieval of gastric or intestinal contents, which is accompanied by a high risk of severe purulent-inflammatory complications.

Instrumental control and monitoring

The modern, most simple, and accessible method for diagnosing injuries of the great vessels of the mediastinum, heart, and lung root is ultrasonography (ultrasound) with Doppler imaging. This method allows not only reliably visualizing fluid or air accumulations but also measuring their volume.

Before any invasive manipulation in closed chest trauma, comprehensive monitoring is mandatory, including:

1. Chest radiography.
2. Comprehensive ultrasound of internal organs.
3. Computed tomography (CT) of the chest cavity.

In addition to visualization, mandatory electrocardiography (ECG) recording is recommended for all patients for diagnostic purposes.

Spinal canal and nerve interventions

Spinal canal puncture is performed in a hospital setting when a generalized form of meningococcal infection is suspected, or in the presence of general cerebral or focal neurological symptoms. The procedure is performed strictly in the absence of contraindications, with the patient lying on their side with knees drawn to the chest and head tilted forward.

Puncture interventional procedures in the cervical and thoracic spine are also widely used:

• Epidural analgesia: Indicated for pain caused by intervertebral disc degeneration or herniation if conservative therapy is ineffective. Local anesthetics (lidocaine, bupivacaine, ropivacaine) and glucocorticoids (dexamethasone) are used. Performed via an interlaminar approach under X-ray guidance using contrast (iopromide, iohexol). The transforaminal approach at the cervical level is undesirable due to the risk of severe neurological complications.
• Pulsed radiofrequency ablation of the dorsal root ganglion: Used when preceding epidural analgesia is insufficiently effective. The effect lasts from 3 to 12 months.

Important: These interventions in the thoracic region are not indicated if the pain is caused by degenerative changes in the facet joints.

Anesthetic management of short procedures

For anesthesia during short surgical procedures lasting 10–20 minutes (opening of abscesses and phlegmons, reduction of dislocations, bone fragment reposition), barbituric acid derivatives—sodium thiopental and hexobarbital—are used. These drugs provide a rapid onset of anesthetic sleep without an excitation stage, as well as rapid awakening.

• Features: The clinical picture of anesthesia for both drugs is identical, but hexobarbital causes less respiratory depression.
• Technique: Use only freshly prepared 1% solutions in isotonic NaCl solution. Administration is carried out slowly (1 ml per 10–15 seconds), starting with a sensitivity test (3–5 ml with a 30-second wait). The maximum dose should not exceed 1000 mg.
• Complications: Respiratory depression (characteristic of sodium thiopental) and a drop in blood pressure are possible. In case of apnea, mechanical ventilation with a mask is immediately initiated, and in case of a blood pressure drop, drug administration is stopped.

Class and exam questions

What else to study on this topic

• Clinical picture and monitoring of intravenous anesthesia
• Complications in the use of sodium thiopental
• Pulsed radiofrequency ablation of the dorsal root ganglion
• Ultrasonic Dopplerography in chest trauma
• Technique of cervical epidural analgesia

Other topics in the "Additional Topics" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.