Thoracostomy Tube

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	III) THORACOSTOMY TUBE PLACEMENT
Intubation PTTNV Cricothyrotomy Thoracostomy Thoracotomy DPL	1) INDICATIONS a) Hemothorax b) Pneumothorax c) Open pneumothorax d) Prophylaxis pre-operatively in trauma patient with significant chest trauma, e.g., flail chest 2) TECHNIQUE a) Use 5^th intercostals space mid axillary line b) Prep c) Use local anesthesia if patient awake d) Make 2-3 cm transverse incision one interspace below the site of desired entry e) Use blunt dissection with a curved spreading clamp f) Use clamp during expiration to puncture through into pleural space, spread clamp to widen space g) Use finger to explore the space for pleural adhesions and to verify location h) Grasp the tip of the tube with a large hemostat and insert the tube into the thoracic cavity. Advance the tube superiorly and posteriorly i) Connect tube to under water seal j) Close wound with heavy black silk sutures k) Place dressing over tube 3) COMPLICATIONS a) Malpositioning, with liver, spleen, or diaphragmatic injury b) Insertion into pulmonary parenchyma c) Exsanguination through chest tube from massive intrathoracic injury

	Figure 6-5. Standard sites for tube thoracostomy: A. Second intercostal space, mid-clavicular line, for air. B. Fifth intercostals space, mid-axillary line, for fluid.	Figure 6-8. Use of a needle to puncture the pleura and establish the presence of blood or air in the pleural space. This not only is diagnostic but also may be a temporary therapeutic maneuver in a tension pneumothrax. (Redrawn from Richards. V.: Tube thoracostomy. J. Fam. Pract. 6:631. 1978.)
Intubation PTTNV Cricothyrotomy Thoracostomy Thoracotomy DPL
	Figure 6-7. Infiltration of skin and pleura with local anesthetic. (Redrawn from Hughes. W. T. and Buescher. E. S.: Pediatric Procedures. 2nd ed. Philadelphia. W. B. Saunders Co. 1980. p. 234.)	Figure 6-9. Location of the intercostals neurovascular bundle. (From Millikan. J. S. et al.: Complications of tube thoraostomy for acute trauma. Am. J. Surg. 140:739. 1980.)

	Figure 6-10. The skin wound is made one intercostals space below the space through which the tube will pass (A). Blunt dissection is carried subcutaneoulsy (B) and into the pleural space (C). A common error in technique is to attempt to insert a large chest tube through a skin incision that is too small. (Redrawn from Hughes. W. T. and Buescher. E.S.: Pediatric Procedures. Philadelphia. W.B. Saunder Co., 1980. p. 237.)	Figure 6-11. One accomplishes blunt dissection by forcing the closed points of the clamp forward and then spreading the tips and pulling back with the points spread. One must be certain to make an adequate opening in the pleura. (From Bricker. D. L.: Safe, effective tube thoracostomy. E. R. Reports 2:49-52. 1981.)
Intubation PTTNV Cricothyrotomy Thoracostomy Thoracotomy DPL
	Figure 6-12. Loading a chest tube on a Carmalt or large Hemostat	Figure 6-13. Using the finger as a guide, one places the tip in the pleural cavity. (From Millikan. J. S. et al.: Complications of tube thoracostomy for acute trauma. Am. J. Surg. 140:739. 1980.)

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