Chest tube: Difference between revisions
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==Indications== | ==Indications== | ||
#Hemothorax | #Hemothorax | ||
#Abscess | #Abscess | ||
#Empyema | #Empyema | ||
#[[Traumatic Pneumothorax]] (some) | |||
#[[Spontaneous Pneumothorax]] (some) | |||
==Relative Indications== | ==Relative Indications== | ||
# | #Penetrating thoracic injury and need for positive pressure ventilation | ||
#Profound hypoxia/hypotension in pt with penetrating chest injury | #Profound hypoxia/hypotension in pt with penetrating chest injury | ||
#Profound hypoxia/hypotension and signs of hemothorax | #Profound hypoxia/hypotension and signs of hemothorax | ||
Line 13: | Line 13: | ||
==Relative Contraindications== | ==Relative Contraindications== | ||
#Overlying skin infection | #Overlying skin infection | ||
#Coagulopathy | |||
#Multiple pleural adhesions | |||
==Equipment Needed== | ==Equipment Needed== | ||
#Chest | #Chest tube | ||
##14-28F for pneumothorax | |||
##32-40F for hemothorax | |||
#Scalpel | |||
#Clamp (Kelly) | |||
#Sterile drapes | #Sterile drapes | ||
#Silk sutures | #Silk sutures | ||
#Syringes and needles for anesthesia | #Syringes and needles for anesthesia | ||
#Lidocaine | #Lidocaine | ||
#Betadine | #Betadine | ||
#Sterile gown/gloves | #Sterile gown/gloves | ||
#Face shield | #Face shield | ||
#Pleur-evac | #Pleur-evac | ||
==Procedure== | ==Procedure== | ||
#Expose insertion site by moving upper extremity above head on affected side | #Expose insertion site by moving upper extremity above head on affected side | ||
##Insertion site = | ##Insertion site = mid- to ant axillary line at 4th/5th intercostal space | ||
###~Nipple line in men, inframammary crease in women | ###~Nipple line in men, inframammary crease in women | ||
#Clean w/ betadine and drape | #Clean w/ betadine and drape | ||
#Confirm rib space and anesthetize w/ | #Confirm rib space and anesthetize w/ up to 5mg/kg of lido w/ or w/o epi | ||
##Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space | ##Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space | ||
#Incise along upper border of the lower rib of the intercostal space | #Incise along upper border of the lower rib of the intercostal space | ||
Line 47: | Line 49: | ||
#Feed the chest tube until all the holes are inside the thoracic cavity | #Feed the chest tube until all the holes are inside the thoracic cavity | ||
##Aim superoanterior for ptx; aim posteriorly for hemothorax | ##Aim superoanterior for ptx; aim posteriorly for hemothorax | ||
###Controversial as to whether this is important | |||
#Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction) | #Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction) | ||
#Secure tube with silk suture and cover with gauze and cloth tape | #Secure tube with silk suture and cover with gauze and cloth tape |
Revision as of 03:33, 17 July 2011
Indications
- Hemothorax
- Abscess
- Empyema
- Traumatic Pneumothorax (some)
- Spontaneous Pneumothorax (some)
Relative Indications
- Penetrating thoracic injury and need for positive pressure ventilation
- Profound hypoxia/hypotension in pt with penetrating chest injury
- Profound hypoxia/hypotension and signs of hemothorax
Relative Contraindications
- Overlying skin infection
- Coagulopathy
- Multiple pleural adhesions
Equipment Needed
- Chest tube
- 14-28F for pneumothorax
- 32-40F for hemothorax
- Scalpel
- Clamp (Kelly)
- Sterile drapes
- Silk sutures
- Syringes and needles for anesthesia
- Lidocaine
- Betadine
- Sterile gown/gloves
- Face shield
- Pleur-evac
Procedure
- Expose insertion site by moving upper extremity above head on affected side
- Insertion site = mid- to ant axillary line at 4th/5th intercostal space
- ~Nipple line in men, inframammary crease in women
- Insertion site = mid- to ant axillary line at 4th/5th intercostal space
- Clean w/ betadine and drape
- Confirm rib space and anesthetize w/ up to 5mg/kg of lido w/ or w/o epi
- Must anesthetize skin, soft tissue, muscle, periosteum, and pleural space
- Incise along upper border of the lower rib of the intercostal space
- Ensure that incision is large enough to fit your finger through
- Use curved clamp to bluntly dissect through the muscle until you reach the rib
- Angle the clamp to go above and over the rib and push until enter the pleural space
- Open the clamp and pull it out with the clamp still open to create a larger tract
- Clamp the prox end of the chest tube and pass it along the tract into the pleural cavity
- It helps to have your finger in the tract and pass the tube along your finger
- Once in the space, remove the clamp
- Feed the chest tube until all the holes are inside the thoracic cavity
- Aim superoanterior for ptx; aim posteriorly for hemothorax
- Controversial as to whether this is important
- Aim superoanterior for ptx; aim posteriorly for hemothorax
- Attach distal end of tube to the pleur-evac and place on suction (20-30cmH2O suction)
- Secure tube with silk suture and cover with gauze and cloth tape
- Obtain CXR position of tube
Complications
- Exsanguination (2/2 removing the tamponade effect of the hemothorax)
- Clamp tube immediately; take pt to the OR for emergent thoracostomy
- Air leak
- Reason why you never clamp the tube once it's in place (could cause tension ptx)
- Infection
- Damage to nerves/vessels/heart/lung/diaphragm/abdomen
- Improper positioning of the tube
- Tension pneumothorax
- Failure to drain