Chest tube

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. 14-28F for pneumothorax
    2. 32-40F for hemothorax
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
      1. ~Nipple line in men, inframammary crease in women
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 muscle until 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 superoanterior for ptx; aim posteriorly for hemothorax
11. Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction)
12. Secure tube with silk suture and cover with gauze and cloth tape
13. Obtain CXR position of tube

Complications

1. Exsanguination (2/2 removing the tamponade effect of the hemothorax)
   1. Clamp tube immediately; take pt to the OR for emergent thoracostomy
2. Air leak
   1. Reason why you never clamp the tube once it's in place (could cause tension ptx)
3. Infection
4. Damage to nerves/vessels/heart/lung/diaphragm/abdomen
5. Improper positioning of the tube
6. Tension pneumothorax
7. Failure to drain

See Also

• Traumatic Pneumothorax
• Spontaneous Pneumothorax

Source

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