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Questions Answered: 127

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126
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Procedural Skills (SLO6)

Question 90 of 127

You are asked to perform an open thoracostomy and chest drain insertion on a trauma patient with a large pneumothorax. You are identifying the correct landmarks. The safe triangle is bordered anteriorly by which of the following?

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 and well within the safe triangle.
  • The “triangle of safety”is bordered by:
    • the anterior border of the latissimus dorsi muscle
    • the lateral border of the pectoralis major muscle
    • a line superior to the horizontal level of the nipple
    • an apex below the axilla

Chest Drain Insertion: Open Thoracostomy

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
  • 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

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