4a - Tube Thoracostomy Flashcards
Indications for thoracostomy
Pneumothorax
Hemothorax
Hemopneumothorax
Pleural effusion
CI’d to thoracostomy
Absolute - none
Relative - blood dyscrasia, anticoagulation
Complications of thoracostomy
Bleeding Infx Injury to surrounding stuff Anesthetic reaction Poor cosmesis
Before thoracostomy
Get a CXR
Prepare materials for thoracostomy
- chest tube • Hemostats • 10 blade scalpel • Scissors • Anesthetic • Skin marker • Syringes with needles • Drape • 2 silk or higher with swaged needle • Skin prep solution
After thoracostomy
Get a CXR
Triangle of safety
Medial border - pectoralis muscle
Lateral border - latissimus dorsi
Inferior border - 4th or 5th intercostal space
Insertion site for thoracostomy
Overtop the 5th rib AAL in triangle of safety
Anesthetize
Generous amount
Overtop the rib, wheel in skin, skive deeper into tissue into pleural cavity and inject while withdrawing
Procedure
1.5 to 2 inch incision through skin on top of the 5th rib
Blunt dissect with hemostat into rib
Then skive cephalad into the 4th or 5th intercostal space
Breach the pleural cavity and spread hemostat
Remove hemostat and sweep with finger
Insert tube, aim towards the apex
suture in place with 2 silk
Stuff petroleum gauze around insertion site
Absorbent bandage
Set up pleur-vac
Section chamber with 20cm water (zero wall suction)
Air leak chamber 2cm water
OR
Hook up to suction and set dial to 20, and air leak chamber with 2cm water
When initially attached, what will happen with the air leak meter?
It will bubble violently then settle within one minute (or longer if there’s an air leak)
Initial setting for chest tube should be on:
Water seal (no wall suction)
If you do wall suction early, you can cause ARDS
So wait an hour or two before you switch to wall suction (if you have to)
Keep drainage system
Below the chest
Avoid dependent loops
Patients can walk around with it
Every day, check:
For air leak
Measure drainage
CXR
