Tube Thoracostomy Module Vic V. Vernenkar, D.O. Dept. of Surgery St. Barnabas Hospital

Indications 1. Drainage of hemothorax, or large pleural effusion of any cause 2. Drainage of large pneumothorax (greater than 25%)

Indications 3. Prophylactic placement of chest tubes in a patient with suspected chest trauma before transport to specialized trauma center 4. Flail chest segment requiring ventilator support, severe pulmonary contusion with effusion

Contraindications 1. Infection over insertion site 2. Uncontrolled bleeding diathesis

Materials 1. Chest tube; OR Fuhrman catheter 2. Chest tube suction unit (Pleurevac R ), tubing, wall suction hookup 3. Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver, scissors 4. Packet of 0 or 1.0 silk suture on a curved needle

Materials Tape, gauze 2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration Sterile prep solution; Mask, gown and gloves

Size Adult male28-38F Adult Female28F Child18F Infant12-14F

Preprocedure patient education 1. Obtain informed consent 2. Inform the patient of the possibility of major complications and their treatment 3. 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-ray VERIFY SITE OF INSERTION!!!!!! 2. Select site for insertion: mid-axillary line, between 4 th and 5 th ribs…this 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 ribs 5. 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 4 th and 5 th 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

Insertion Insert 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 4 th and 5 th ribs! 2. Bleeding; This usually ceases 3. Cardiac puncture. Again preventable, carefully control the tube going in, DO NOT USE TUBES WITH TROCARS 4. 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 out 2. Indications and contraindications for the procedure on this patient 3. Procedure used 4.Any complications, or none 5.Who was notified of any complication (family, attending physician) 6. Order of STAT portable X-ray IF 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, pleura 2. Indications, and contraindications of this procedure 3. Use of sterile technique and universal precautions 4. Technical ability 5. Appropriate documentation 6. Understanding of potential complications and their correction