(SKILLS/HANDS-ON) Chest Tubes Rebecca Carman, MSN, ACNP-BC Nurse Practitioner, Trauma Services, Intermountain Medical Center, Intermountain Healthcare Amanda Shumway, PA-C APC Trauma and Critical Care Resident Intermountain Medical Center, Salt Lake City, Utah Thomas W. White, MD, FACS, CNSC Trauma Surgery/Critical Care, Medical Director Nutrition Support Service, Shock Trauma ICU Attending, Intermountain Medical Center; Clinical Professor of Surgery, University of Utah Surgery Residency Program; Salt Lake City, Utah Objectives: Identify injuries or conditions that necessitate chest tube treatment Describe and demonstrate placement of chest tube Review complications of chest tube insertion
Chest Tubes Rebecca Carman, MSN, ACNP BC Thomas W. White, MD, FACS, CNSC Trauma and Critical Care Intermountain Medical Center, SLC, UT September 2015
Chest Tubes Placed into the pleural cavity to drain air or fluid collections from the pleural space Can be used to instill medications for pleurodesis
Indications Pneumothorax spontaneous, traumatic, tension, bronchopleural fistula (post op or mechanical ventilation), iatrogenic after central line Traumatic arrest (bilateral) Hemothorax blunt or penetrating trauma Pleural effusion sterile, malignant, chylothorax, empyema (infected) Pleurodesis treatment of refractory effusion
Trivia What is the diagnosis? Would you place a chest tube?
Preparation Antibiotic prophylaxis prior to placement of Tube selection: consider the indication Type: i.e. Blake, Thal Quick Size: 32F 36F or larger for hemothorax 14F Iatrogentic PTx, Larger 32F 36F if traumatic PTX o May need to drain blood
Needle Thoracostomy Reserve for pts with hemodynamic compromise 2 nd rib midclavicular line, superior margin 14 gauge angiocath with 5 10 ml syringe Rush of air is heard Remove needle, leave angiocatheter 13
Tube Thoracostomy Insertion site 4 5 th intercostal space Mid or anterior axillary line IV pain meds, IV anesthetic (i.e. propofol or ketamine) Local anesthesia with lidocaine 2 3 cm of skin and SQ tissue down to periosteum and pleural space Sterile prep (gown, gloves, mask etc.) Cleanse area with chlorhexidine 14
Tube Thoracostomy 1 2 cm incision with #10 blade rib below rib space to be used Dissect through subcutaneous tissues with curved clamp, to rib margin Clamp is angled OVER the rib Digital exploration feel for adhesions and for lung, heart and diaphragm Advance large bore chest tube (32 36F) with clamp and direct posteriorly and apically (PTX) or inferiorly (HTX)
Tube Thoracostomy Observe for fogging of chest tube, blood output Last drainage hole in the chest by at least 2 cm Rotate the tube Connect to pleurovac and secure connections Suture the tube in place Obtain a CXR Monitor drainage Beware of re expansion pulmonary edema
Seldinger Technique Smaller tubes that drain air and non viscous fluid Procedure Insert introducer needle into pleural space Insert guide wire through needle Should pass without resistance
Procedure Seldinger Technique Pass the dilators over the guide wire to dilate the tract Pass the chest tube/dilator combination into the pleural space Remove dilator/wire, leaving tube Suture into place
Acute Complications Technique Hemothorax, usually from laceration of intercostal vessel (may require thoracotomy) Lung laceration (pleural adhesions not broken down) Diaphragm/abdominal cavity penetration (placed too low) Stomach/colon injury (diaphragmatic hernia not recognized) Tube placed subcutaneously (not in thoracic cavity) Tube placed too far (pain) Tube falls out (not secured)
Late Complications Tube obstruction (clot, lung) Retained hemothorax Empyema Pneumothorax after removal (poor technique)
Procedure Chest Tube Removal Area is cleansed Sutures removed Sterile occlusive dressing is ready Patient holds breath (end inspiration or end expiration) Rapidly pull tube and cover with dressing Chest x ray in several hours or following day Eval for PTX
References Advanced Trauma Life Support. The American College of Surgeons. 2012. Bailey RC. Complications of tube thoracostomy in trauma. Accid Emerg Med. 2000;17:111 114 Doelken, Peter. Placement and management of thoracostomy tubes. UptoDate 2014. www.trauma.org/archive/thoracic/chestdrain.html