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Procedural Skills (SLO6)
Question 32 of 127
A 23 year old cyclist is brought into the Emergency Department following a collision with a car. The patient is poorly responsive, tachycardic, hypotensive and hypoxic. During the primary survey you note distended neck veins and tracheal deviation towards the right side. There is reduced air entry and hyperresonant percussion note over the left chest. You proceed to perform open thoracostomy. Which of the following is the most appropriate site for insertion?
Answer:
- Identify the site for insertion of the chest tube in the 5th intercostal space (ICS). This site corresponds to the level of the nipple or inframammary fold. The insertion site should be between the anterior and midaxillary lines.
- Confirm that defined site is well within the safe triangle: The triangle is bordered anteriorly by the lateral edge of pectoralis major, laterally by the lateral edge of latissimus dorsi, inferiorly by the line of the fifth intercostal space and superiorly by the base of the axilla.
- Avoid placement directly over an area of infected soft tissue e.g. cellulitis, skin abscess
- Consider 4th ICS in patients who are pregnant, have massive ascites or large haemoperitoneum where the increased intra-abdominal contents can elevate the diaphragm
Chest Drain Insertion: Open Thoracostomy
Procedural Skills (SLO6)
Last Updated: 9th January 2024
Indications
- Tension pneumothorax
- Open pneumothorax
- Simple pneumothorax in some cases
- Haemothorax
- Severe surgical emphysema constricting respiration
- Patients with penetrating thoracic trauma who are intubated or about to be intubated
- Patients at risk of pneumothorax who are about to undergo air transport
Contraindications
- Absolute
- The need for resuscitative thoracotomy
- Relative
- Coagulopathy
- Overlying skin infection
Clinical Anatomy
Safe Triangle. (Image by Brantigan, Otto C. [Public domain], via Wikimedia Commons)
Procedure
- Gather supplies, sterile drapes, and antiseptic, tube thoracostomy kit (tray) and appropriately sized chest tube (28-32 Fr). Prepare the underwater seal and collection device.
- Position the patient with the ipsilateral arm extended overhead and flexed at the elbow (unless precluded by other injuries). Use an assistant to maintain the arm in this position.
- Widely prep and drape the lateral chest wall, include the nipple, in the operative field.
- Identify the site for insertion of the chest tube in the 5th intercostal space (ICS). This site corresponds to the level of the nipple or inframammary fold. The insertion site should be between the anterior and midaxillary lines.
- Confirm that defined site is well within the safe triangle. The “triangle of safety”is bordered by:
- the anterior border of the latissimus dorsi muscle posteriorly
- the lateral border of the pectoralis major muscle anteriorly
- a line superior to the horizontal level of the nipple inferiorly
- an apex below the axilla superiorly
- Avoid placement directly over an area of infected soft tissue e.g. cellulitis, skin abscess
- Consider 4th ICS in patients who are pregnant, have massive ascites or large haemoperitoneum where the increased intra-abdominal contents can elevate the diaphragm
- Confirm that defined site is well within the safe triangle. The “triangle of safety”is bordered by:
- Inject the site liberally with local anaesthesia to include the skin, subcutaneous tissue, rib periosteum, and pleura.
- While the local anaesthetic takes effect, use the thoracostomy tube to measure the depth of insertion. Premeasure the estimated depth of chest tube by placing the tip near the clavicle with a gentle curve of chest tube toward incision. Evaluate the marking on the chest tube that correlates to incision, ensuring the sentinel hole is in the pleural space. Often the chest tube markings will be at 10–14 at the skin, depending on the amount of subcutaneous tissue (e.g. obese patients).
- Make a 2- to 3-cm incision parallel to the ribs at the predetermined site, and bluntly dissect through the subcutaneous tissues just above the rib (to protect neurovascular bundle).
- Puncture the parietal pleura with the tip of the clamp while holding the instrument near the tip to prevent sudden deep insertion of the instrument and injury to underlying structures. Advance the clamp over the rib and spread to widen the pleural opening. Take care not to bury the clamp in the thoracic cavity, as spreading will be ineffective. Air or fluid will be evacuated. With a sterile gloved finger, perform a finger sweep to clear any adhesions and clots (i.e. perform a finger thoracostomy).
- Place a clamp on the distal end of the tube. Using either another clamp at the proximal end of the thoracostomy tube or a finger as a guide, advance the tube into the pleural space to the desired depth.
- Look and listen for air movement and bloody drainage; “fogging” of the chest tube with expiration may also indicate tube is in the pleural space.
- Remove the distal clamp and connect the tube thoracostomy to an underwater seal apparatus with a collection chamber. Zip ties can be used to secure the connection between the thoracostomy tube and the underwater seal apparatus.
- Secure the tube to the skin with heavy, nonabsorbable suture.
- Apply a sterile dressing and secure it with wide tape.
- Obtain a chest x-ray.
- Reassess the patient.
Complications
- Persistent or recurrent pneumothorax/pleural effusion
- Improper placement of tube
- Tube dislodgement
- Kinking/compression of tube
- Obstruction of tube with blood, tissue or fluid
- Large primary air leak (air leak rate greater than air evacuation by tube)
- Disconnection from underwater-seal apparatus
- Bleeding
- Local bleeding
- Haemothorax (lung or intercostal artery injury)
- Haemoperitoneum (liver or spleen injury)
- Organ laceration or puncture
- Stomach, colon or diaphragm
- Lung
- Liver or spleen
- Infection
- Local infection
- Empyema
- Other
- Pain at site
- False passage
- Subcutaneous emphysema
- Re-expansion pulmonary oedema
- Intercostal or long thoracic nerve injury
- Anaphylactic or allergic reaction to surgical preparation or anaesthesia
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
