Tube Thoracostomy Module

Posted by e-Medical PPT
Tube Thoracostomy Module
Indications
1. Drainage of hemothorax, or large pleural effusion of any cause
2. Drainage of large pneumothorax (greater than 25%)
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

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

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

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 ribs…this is usually on a line lateral to the nipple
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

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
-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
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
-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-Obtain post procedure chest Xray for placement; Tube may need to be advanced or withdrawn slightly..

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