Thoracostomy

by Dr. Lindsey Edwards
Presented at Follow-Up Rounds

Indications

Landmarks

4th-5th intercostal space, just anterior to mid-axillary line and just lateral/superior to nipple
- In pregnant patients go up to 3-4^th intercostal space
Triangle of safety: Pectoralis major, mid axillary line (or latissimus if visible) and level of nipple (in men)

Materials

In our bundle
- Chest tube tray
- Side pack attached to our trays
  - Xeroform
  - Sterile drapes
  - 10 blade
  - 0-silk
Not in bundle, but in trauma bay
- Chest tube (≥32 can be used for a hemothorax)
- Pleur-Evac
- Sterile gloves
- Sterile gown
- Mask/cap
- Betadine
- 4x4s
- Silk tape
- +/- restraint to hold arm in place
- Mayo stand
Not in trauma bay
- Syringe (20cc)
- 2% lidocaine
- 18 gauge needle (for drawing up)
- 22 gauge needle (for injecting)

Patient placed supine with ipsilateral arm abducted fully and restrained
Prepare skin with betadine, drape field
Anesthetize site including periosteum
Make a 2 cm horizontal incision (parallel to the rib) at the upper border of lower rib
Dissect subcutaneous tunnel through the tissues, plunge kelly through pleura, spread kelly to widen hole, insert finger to help verify entry into cavity
When passing tube into chest (with both ends clamped), aim it apically for pneumothorax and inferiorly/posteriorly to relieve fluid
Secure the tube; once you break sterile field, it cannot be pushed further into the chest
Suturing: use a simple interrupted 0-silk to close the skin from the incision you made and then wrap the sutures around the chest tube.
Use xeroform gauze around the chest tube itself, and then tape 4×4 and tape over top
Secure the chest tube to pleur-evac tubing
- 20 to 30 cm H2O of suction

Fentanyl (less vasoactive compared to other agents)
Ketamine
Ancef
- For penetrating trauma + hemothorax
- Decreases risk of empyema/pneumonia

Persistent air leak – check tubing and equipment first, otherwise consider undiagnosed bronchial injury
OR indication: >1.5 L initial output or continued drainage 150-200 cc/hour for 2-4 hours (hemothorax)
When the Kelly is clamped on the end of the chest tube for insertion, ensure it does not extend past the end of the tube. The kelly tip may damage structures when inserted through the chest wall.
Tube malposition is the most common complication
Smaller tubes are associated with less pain, less post procedure complications (infection, abscess etc) compared to larger tubes, and are equally efficient in getting fluid/air out of the pleural cavity.