Chest tube: Difference between revisions
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==Indications==
==Indications==
# [[Traumatic Pneumothorax]]
#[[Traumatic Pneumothorax]]
# [[Spontaneous Pneumothorax]] (some)
#[[Spontaneous Pneumothorax]] (some)
# hemothorax
#Hemothorax
# abscess
#Abscess
# empyema
#Empyema


==Relative Indications==
==Relative Indications==
# rib fractures and positive pressure ventilation
#Rib fx and positive pressure ventilation
# profound hypoxia/hypotension in patient with penetrating chest injury
#Profound hypoxia/hypotension in pt with penetrating chest injury
# profound hypoxia/hypotension and signs of hemithorax
#Profound hypoxia/hypotension and signs of hemothorax


==Contraindications==
==Relative Contraindications==
# overlying skin infection  
#Overlying skin infection  


==Equipment Needed==
==Equipment Needed==
# Chest Tube Tray
#Chest Tube Tray
# sterile drapes  
#Sterile drapes  
# silk sutures
#Silk sutures
# curved clamps
#Curved clamps
# syringes and needles for anesthesia
#Syringes and needles for anesthesia
# scaple
#Scapel
# Lidocaine
#Lidocaine
# Betadine
#Betadine
# Sterile gown
#Sterile gown/gloves
# sterile gloves
#Face shield
# face shield
#Chest tube
# Chest tube (18-20 French for pneumothorax, 32-26F for hemothorax, 38-40 French for trauma pt)
##18-20F for pneumothorax
# Pleura-vac
##32-26F for hemothorax
##38-40F for trauma pt
#Pleur-evac
   
   
==Procedure==
==Procedure==
# expose patients lateral thorax by moving the upper extremity above the head on the affected side
#Expose insertion site by moving upper extremity above head on affected side
# note landmarks to help decide where you will be inserting your tube (lateral thorax, midaxillary line at 4th/5th intercostal space (~nipple line in males or 5cm above the sternoxiphoid junction in females)
##Insertion site = midaxillary line at 4th/5th intercostal space (~nipple line in males, 5cm above the sternoxiphoid junction in females)
# prep skin with betadine and drape with sterile drapes
#Clean w/ betadine and drape
# confirm the rib space where you are going to insert the tube and anesthetize the area with 10-20cc's of lidocaine w/epinephrine making sure to anesthetize the skin, soft tissues, muscle, periosteum, and pleural space
#Confirm rib space and anesthetize w/ 10-20cc of lido w/ epi
# Make an incision along the upper border of the lower rib below the intercostal space that you are going to use. **make sure the incision is large enough that your finger can easily go through it
##Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space
# Using a curved clamp, create a tract by bluntly dissecting the muscle tissue until you reach the rib
#Incise along upper border of the lower rib of the intercostal space
# Angle the clamp to go above and over the rib (avoiding intercostal vessels and nerves) and push until you enter the pleural space
##Ensure that incision is large enough to fit your finger through
# Open the clamp and pull it out with the clamp still open creating a larger tract  
#Use curved clamp to bluntly dissect through the muscleuntil you reach the rib
# Clamp the end of your chest tube and pass it along the tract into the pleural cavity (it helps if you have your finger in the tract in the space and pass the tube along your finger so you know you're in the right space)
#Angle the clamp to go above and over the rib and push until enter the pleural space
# Once in the space, remove the clamp and feed the chest tube until all the holes are inside the thoracic cavity aiming it toward the apex
#Open the clamp and pull it out with the clamp still open to create a larger tract  
# Attach the other end of the chest tube to your pleura-vac and place on suction
#Clamp the prox end of the chest tube and pass it along the tract into the pleural cavity
# Secure the tube with silk suture (in the kit) and cover with gauze and cloth tape
##It helps to have your finger in the tract and pass the tube along your finger
# re-examine patient to see if you got a desired effect and get a CXR to confirm placement and position of tube
#Once in the space, remove the clamp
#Feed the chest tube until all the holes are inside the thoracic cavity
##Aim toward apex for ptx; aim toward bottom for hemothorax
#Attach distal end of tube to the pleur-evac and place on suction
#Secure tube with silk suture and cover with gauze and cloth tape
#Obtain CXR position of tube


==Complications==
==Complications==
# bleeding (causing a hemothorax)
#Bleeding (causing a hemothorax)
# infection
#Infection
# damage to nerves/vessels/heart/lung/diaphragm/abdomen
#Damage to nerves/vessels/heart/lung/diaphragm/abdomen
# air leak
#Air leak
# improper positioning of the tube
#Improper positioning of the tube
# tension pneumothorax  
#Tension pneumothorax  
# failure to drain  
#Failure to drain  
   
   
==See Also==
==See Also==

Revision as of 02:27, 17 July 2011

Indications

  1. Traumatic Pneumothorax
  2. Spontaneous Pneumothorax (some)
  3. Hemothorax
  4. Abscess
  5. Empyema

Relative Indications

  1. Rib fx and positive pressure ventilation
  2. Profound hypoxia/hypotension in pt with penetrating chest injury
  3. Profound hypoxia/hypotension and signs of hemothorax

Relative Contraindications

  1. Overlying skin infection

Equipment Needed

  1. Chest Tube Tray
  2. Sterile drapes
  3. Silk sutures
  4. Curved clamps
  5. Syringes and needles for anesthesia
  6. Scapel
  7. Lidocaine
  8. Betadine
  9. Sterile gown/gloves
  10. Face shield
  11. Chest tube
    1. 18-20F for pneumothorax
    2. 32-26F for hemothorax
    3. 38-40F for trauma pt
  12. Pleur-evac

Procedure

  1. Expose insertion site by moving upper extremity above head on affected side
    1. Insertion site = midaxillary line at 4th/5th intercostal space (~nipple line in males, 5cm above the sternoxiphoid junction in females)
  2. Clean w/ betadine and drape
  3. Confirm rib space and anesthetize w/ 10-20cc of lido w/ epi
    1. Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space
  4. Incise along upper border of the lower rib of the intercostal space
    1. Ensure that incision is large enough to fit your finger through
  5. Use curved clamp to bluntly dissect through the muscleuntil you reach the rib
  6. Angle the clamp to go above and over the rib and push until enter the pleural space
  7. Open the clamp and pull it out with the clamp still open to create a larger tract
  8. Clamp the prox end of the chest tube and pass it along the tract into the pleural cavity
    1. It helps to have your finger in the tract and pass the tube along your finger
  9. Once in the space, remove the clamp
  10. Feed the chest tube until all the holes are inside the thoracic cavity
    1. Aim toward apex for ptx; aim toward bottom for hemothorax
  11. Attach distal end of tube to the pleur-evac and place on suction
  12. Secure tube with silk suture and cover with gauze and cloth tape
  13. Obtain CXR position of tube

Complications

  1. Bleeding (causing a hemothorax)
  2. Infection
  3. Damage to nerves/vessels/heart/lung/diaphragm/abdomen
  4. Air leak
  5. Improper positioning of the tube
  6. Tension pneumothorax
  7. Failure to drain

See Also

Source

http://www.trauma.org/archive/thoracic/CHESTdrain.html

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