Tube Thoracostomy Module

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Tube Thoracostomy Module

• Vic V. Vernenkar, D.O.
• Dept. of Surgery
• St. Barnabas Hospital

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Indications

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

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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
  
•  

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Contraindications

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

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Materials

•  
• 1. Chest tube OR Fuhrman catheter
• 2. Chest tube suction unit (PleurevacR), 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

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Materials

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

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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
  
•  

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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 4th and 5th ribsthis is usually on a
  line lateral to the nipple

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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
  

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Chest tube insertion

• After infiltrating insertion site with local
  anesthetic, make a 3-4 cm incision through skin
  and subcutaneous tissues between the 4th and 5th
  ribs, parallel to the rib margins

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Incising the Chest wall
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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

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Opening the Incision with Kelly
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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

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Using a Kelly to Guide Insertion
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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
  

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Complications, Prevention, and Management

• 1. Puncture of liver or spleen. This is entirely
  preventable Insertion site is in the nipple
  line, between 4th and 5th 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

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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
  
•  

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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