Tube Thoracostomy ModuleVic V. Vernenkar, D.O.Dept. of SurgerySt. Barnabas Hospital

Indications

1.Drainage of hemothorax, or large pleural effusion of any cause2.Drainage of large pneumothorax (greater than 25%)

Indications3. Prophylactic placement of chest tubes in a patient with suspected chest trauma before transport to specialized trauma center4. Flail chest segment requiring ventilator support, severe pulmonary contusion with effusion

Contraindications

1.Infection over insertion site2.Uncontrolled bleeding diathesis

Materials

1. Chest tube; OR Fuhrman catheter2. Chest tube suction unit (PleurevacR), tubing, wall suction hookup3. Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver, scissors4. Packet of 0 or 1.0 silk suture on a curved needle

Materials

Tape, gauze2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltrationSterile prep solution; Mask, gown and gloves

SizeAdult male28-38FAdult Female28FChild18FInfant12-14F

Preprocedure patient education 1. Obtain informed consent 2. Inform the patient of the possibility of major complications and their treatment3. Explain the major steps of the procedure, and necessity for repeated chest radiographs

Procedure 1. Examine the patient and assess need for placement of a thoracostomy tube. Obtain pre-procedure chest X-rayVERIFY SITE OF INSERTION!!!!!!2. Select site for insertion: mid-axillary line, between 4th and 5th ribsthis is usually on a line lateral to the nipple

Procedure 3. Don mask, gown and gloves; 4.Prep and drape area of insertion. Have patient place ipsilateral arm over head to open up ribs5. Widely anesthetize area of insertion with the 2% lidocaine. Infiltrate skin, muscle tissues, and right down to pleura

Chest tube insertion After infiltrating insertion site with local anesthetic, make a 3-4 cm incision through skin and subcutaneous tissues between the 4th and 5th ribs, parallel to the rib margins

Incising the Chest wall

Insertion-Continue incision through the intercostal muscles, and right down to the pleura-Insert Kelly clamp through the pleura and open the jaws widely, again parallel to the direction of the ribs (this creates a pneumothorax, and allows the lung to fall away from the chest wall somewhat

Opening the Incision with Kelly

InsertionInsert finger through your incision and into the thoracic cavity. Make sure you are feeling lung (or empty space) and not liver or spleen-Grasp end of chest tube with the Kelly forcep (convex angle towards ribs), and insert chest tube through the hole you have made in the pleura. After tube has entered thoracic cavity, remove Kelly, and manually advance the tube in

Using a Kelly to Guide Insertion

Insertion-Clamp outer tube end with Kelly -Suture and tape tube in place-Attach tube to suction unit-Obtain post procedure chest Xray for placement; Tube may need to be advanced or withdrawn slightly

Complications, Prevention, and Management 1. Puncture of liver or spleen. This is entirely preventable; Insertion site is in the nipple line, between 4th and 5th ribs!2. Bleeding; This usually ceases3. Cardiac puncture. Again preventable, carefully control the tube going in, DO NOT USE TUBES WITH TROCARS4. Passage of tube along chest wall instead of into chest cavity. In this case, widen and deepen the dissection between the ribs, and make sure the insertion of the tube follows this path

Documentation in the Medical Record 1.Consent if obtained, time out2. Indications and contraindications for the procedure on this patient3.Procedure used4.Any complications, or none5.Who was notified of any complication (family, attending physician)6. Order of STAT portable X-rayIF YOU PUT IN THE CHEST TUBE YOU MUST CHECK THE RESULTS OF THE X-ray in an expeditious and timely manner

Items for Evaluation of Person Learning This Procedure 1.Anatomy of the chest, lungs, pleura2. Indications, and contraindications of this procedure3.Use of sterile technique and universal precautions4.Technical ability5. Appropriate documentation6.Understanding of potential complications and their correction