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Chest Tube

Clarity in Emergency Medicine

CHEST TUBE INSERTION

Indications

  • Pneumothorax (2) in the following settings:

  1. hemodynamically unstable patient

  2. after needle decompression of a tension pneumothorax

  3. all patients with pneumothorax ventilated with positive pressure

  4. prior to air tranportation

  • Hemothorax (2)

 

Contraindications

  • Known adhesions of the lung to the chest wall

  • Caution in the setting of coagulopathy

 

  1. Prior

Prepare the Patient

  • Explain the procedure if the patient is awake

  • Optimal patient position (hand under head, head end height 30°)

  • Consider systemic analgesia / anxiolytics when needed in hemodynamically stable patients

Prepare the Equipment

  • Chest tube set and chest tube size (3)

  • Multi-chamber system with water seal or equivalent (eg Heimlich valve)

  • Equipment to fixate the chest tube (e.g. suture with 0/0, 1/0 el 2/0 equivalent)

  • Protective equipment (eg mouth protection, rock, sterile gloves)

  1. Procedure

Sterilize and Drape

  • Clean a large area of ​​hemithorax with alcohol or equivalent

  • Place sterile drapes around the work area

Analgesia and Anatomy

  • Identify the safe triangle (cranial to the nipple line)

  • Administer local anesthetic to the dermis, periostasis, intercostal muscles and pleura after aspiration

  • Sufficient dose, eg Lidocaine 1% (10 mg / ml) adults 20 ml, children: < 5 mg / kg

Incision and Dissection

  • 2-4 cm skin incision parallel to the ribs in anesthetized area (4)

  • Blunt dissection with forceps through subcutis to the rib

  • Blunt dissection over the cranial edge of the rib (5) until the pleura is reached (6)

  • The hole in the pleura is widened with the forceps or finger

  • Palpation, confirm that the lung is not adherent to the chest wall

Introducing the Chest Tube

  • Graps the distal part of the chest tube with the forceps (6)

  • The chest tube is inserted along side the finger that palpated the pleura (7)

  • Confirm that air or liquid passes through the chest tube

  • The chest tube is clamped (preferably close to the skin so that change of tube position can be detected)

Fixation and Connect

  • Fixate the chest tube so that it can withstand a traction of 2-3 kg (8)

  • Connect the chest tube to the water seal and start suction

  1. Post

  • Check for air / blood in the drain

  • Check for air leak around the incision

  • Re-evaluation the patient’s ABCs

  • Order a chest X-ray

 

Notes

1-Refers here only to indications for emergent chest tube insertion

2-Pneumo- or hemothorax based on clinical, sonographical or radiological suspicion

3-Tube size:

  • 12 – 20 F for children

  • 16 – 20 F for pneumothorax

  • 24 – 36 F for hemothorax

4-Method to garanty that the incision is carried out in the anesthetized area:

  • Mark the are somewhat prior to sterilization

  • Hold a finger on the area after local anesthesia while taking the scalpel

  • Leave the needle used to apply local anesthesia in the skin while taking the scalpel

5-The forceps is held 1 cm from the skin when pressure is applied to avoid penetrating too deeply

6-The trocar should not be used during the introdution of the chest tube

7-This technique is recommended to insure that the chest tube is not inadvertantly placed in the chest wall.

8-One of the techniques that is recommended (http://www.internetmedicin.se/video select ”thoraxdrän”)

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