Tube Thoracostomy

To evacuate abnormal collections of air or fluid from the pleural space in the following conditions:


imagesPneumothorax


imagesHemothorax


imagesChylothorax


imagesEmpyema


imagesRecurrent pleural effusion


imagesPrevention of hydrothorax after cardiothoracic surgery


CONTRAINDICATIONS



imagesNone for unstable injured patients


imagesRelative Contraindications


   imagesAnatomic abnormalities—pleural adhesions, emphysematous blebs, or scarring


   imagesCoagulopathy


LANDMARKS



imagesThe fourth or fifth intercostal space at the mid- to anterior axillary line, but multiple sites are possible (FIGURE 14.1)


imagesIntercostal nerve and vessels are located along the inferior margin of each rib; therefore, the tube should pass immediately over the superior surface of the lower rib


SUPPLIES



imagesAntiseptic solution, drapes, and towel clips


images1% Lidocaine, 20 mL


images25- and 22-gauge needles and 10-mL syringe


imagesNo. 10 scalpel blade with handle, Kelly clamps (two), and forceps


imagesThoracostomy tube selection


   imagesTrauma: No. 36–40 French


   imagesNontraumatic: No. 24–32 French


   imagesChildren: No. 20–24 French


   imagesInfants: No. 18 French


imagesPleur-evac (collection bottle, underwater seal, suction control)


imagesConnecting tubing


imagesGauze pads, adhesive tape, 4˝ × 4˝ pads, Xeroform gauze dressing


images2, 1, or 0 suture (not 2-0 or 1-0), needle driver, and suture scissors



imagesGeneral Basic Steps


   imagesAnalgesia


   imagesIncision


   imagesBlunt dissection


   imagesVerification


   imagesInsertion


   imagesSecuring the tube


   imagesConfirmation



images


FIGURE 14.1 Possible sites for chest tube placement. (From Connors KM, Terndrup TE. Tube thoracostomy and needle decompression of the chest. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 1997:399.)


TECHNIQUE



imagesPreparation


   imagesOxygen and continuous pulse oximetry monitoring


   imagesIf the patient is stable, administer parenteral analgesics or procedural sedation


   imagesElevate the head of the bed to 30 to 60 degrees


   imagesArm on the affected side is placed over the patient’s head


   imagesSterilize the area where the tube will be inserted with povidone–iodine or chlorhexidine solution


   imagesDrape the area with sterile towels


   imagesAssemble the suction-drain system according to manufacturer’s recommendations; adjust the suction until a steady stream of bubbles is produced in the water column


imagesAnalgesia


   imagesProduce local anesthesia using up to 5 mg/kg of 1% lidocaine with epinephrine (1:100,000)


   imagesInject the subcutaneous area with a small-bore (25-gauge) needle


   imagesGenerously infiltrate the muscle, periosteum, and parietal pleura in the area of the tube’s eventual passage using a larger-bore needle


imagesIncision


   imagesUsing a no. 10 scalpel blade, make at least a 3- to 4-cm transverse incision through the skin and subcutaneous tissue


   imagesOne method is to make the incision at an intercostal space lower than the thoracic wall entry site so that the tube may be “tunneled” up over the next rib


imagesBlunt Dissection


   imagesUse a large Kelly clamp or scissor (this often takes considerable force)


   imagesTrack is created over the rib by pushing forward with the closed points and then spreading and pulling back with the points spread


   imagesPush through the muscle and parietal pleura with the closed points of the clamp until the pleural cavity is entered


   imagesA palpable pop is felt when the pleura is penetrated, and a rush of air or fluid should occur at this point


imagesVerification


   imagesOnce the pleura is penetrated, insert a gloved finger into the chest wall track to verify that the pleura has been entered and that no solid organs are present


   imagesThe finger can be left in place to serve as a guide for tube insertion


imagesInsertion


   imagesIt is recommended that the tube be held in a large curved clamp with the tip of the tube protruding from the jaws


   imagesPass the tube over, under, or beside the finger into the pleural space


   imagesThe tube is advanced superiorly, medially, and posteriorly until pain is felt or resistance is met; then it is pulled back 2 to 3 cm


   imagesEnsure that all the holes in the chest tube are within the pleural space


imagesSecuring the Tube (numerous methods are acceptable)


   imagesClose the remainder of the incision using a large 0 or 1 silk or nylon suture, keeping the ends long


   imagesSuture ends are wrapped and tied repeatedly around the chest tube, then knotted securely. The sutures are tied tightly enough to indent the chest tube slightly to avoid slippage.


   imagesA horizontal mattress (or purse-string) suture is placed approximately 1 cm across the incision on either side of the tube, essentially encircling the tube. This suture helps secure the tube and eventually facilitates closing the incision when the chest tube is removed.


   imagesPlace occlusive dressing of petroleum-impregnated gauze where the tube enters the skin; then cover with two or more gauze pads


   imagesWide cloth adhesive tape can be used to hold the tube more securely in place


imagesConfirmation


   imagesIndicators for correct placement are as follows:


      imagesCondensation on the inside of the tube


      imagesAudible air movement with respirations


      imagesFree flow of blood or fluid


      imagesAbility to rotate the tube freely after insertion


   imagesAttach tube to previously assembled water seal or suction


      imagesObserving bubbles in the water seal chamber when the patient coughs is a good way to check for system patency


   imagesObtain a chest radiograph


COMPLICATIONS



imagesHemothorax


imagesPulmonary edema


imagesBronchopleural fistula


imagesEmpyema


imagesSubcutaneous emphysema


imagesInfection


imagesContralateral pneumothorax


imagesSubdiaphragmatic placement of the tube


imagesLocalized hemorrhage


SAFETY/QUALITY TIPS




imagesProcedural


   imagesThe more urgent the chest tube, the less local anesthesia and the more systemic sedation/analgesia, for purposes of speed. In a chest tube required for emergent hemodynamic stabilization, it is reasonable to skip local anesthesia completely and place the chest tube after, for example, a dissociating dose of ketamine.


   imagesThe more urgent the chest tube, the larger the size of the initial skin incision, for purposes of speed


   imagesDo not use the trocar that comes with many chest tubes. Trocar use is associated with solid organ injury.


   imagesWe recommend inserting the chest tube over a finger that remains in the thorax, to minimize the likelihood of a misdirected chest tube. When a chest tube is advanced blindly through a track, subcutaneous placement is a common complication.


   imagesClamp both ends of the tube during insertion to avoid being contaminated by fluid


   imagesGently but assertively advance the chest tube completely into the pleural space


   imagesAvoid causing a contralateral pneumothorax by not directing the tube toward the mediastinum


imagesCognitive


   imagesTube thoracostomy for unstable patients, as well as tube thoracostomy for stable patients without complicated lung disease (e.g., primary spontaneous pneumothorax), is well within the domain of emergency medicine. Caution and consultation are advised in placing chest tubes on stable patients with complicated lung disease.


   imagesPrimary spontaneous pneumothorax can and often should be managed with less invasive strategies such as placement of a pigtail catheter, needle aspiration, or, in some cases, observation alone


   imagesStable patients (especially older patients or patients with underlying lung disease) thought to have pneumothorax may benefit from computed tomography imaging, as blebs can mimic the appearance of pneumothorax on plain film


   imagesFor a pneumothorax, direct the tube superiorly and anteriorly. For hemothorax, direct the tube posteriorly.


   imagesIf there is no lung reexpansion after chest tube placement, consider the following: (1) the tube may not be in the pleural cavity; (2) the most proximal hole is outside the chest cavity; and (3) there is a large air leak from the tracheobronchial tree.


   imagesImmediate drainage of more than 1,000 mL of blood from the pleural cavity or continued output of at least 200 mL/h is an indication for thoracotomy

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Tube Thoracostomy
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