Chest tube insertion Flashcards
4 indications to insert chest tube for different types of pneumothorax
Tension pneumothorax
Recurrent and persistent pneumothorax
Bilateral pneumothorax
Pneumothorax on positive pressure ventilation
5 other indications
Hemothorax
Empyema
After cardiac and lung surgery
Chylothorax
Malignant effusion
Relative CI
Coagulopathy
Skin infection over the site of incision
Past history of lung surgery or lung disease
Allergy to sterilizer and local anesthesia
phgy dehind cardiac instability in pthx
compression of the vena cava and no blood return
VS pthx
tachycardia
tachypnea
hypota
ultrasound findings
no lung sliding in normal mode
barcode sign - parallel horizontal ligns in M mode
Site for needle decompression
4th or 5ht intercostal space (memlon ish) between ant and mid axillary line
signs of tension pthx (6)
dyspnea
absent or decrease breath sounds
tracheal deviation
subcut emphysema
hyperresonance
unstable VS (hypoTA, tachycardia, tachypnea)
signs of hemothorax
dyspnea
decreased breath sounds
DULLNESS to percussion
NOT tracheal deviaiton
Empyema risk factors (6)
immunocompromised pts
diabetes
receiving immunosuppressants
steroid use
chemotx
ROH and IV drug users
chylothorax cause
thoracic duct injury (milky white effusion)
pleural effusion from CHF - do you put a drain
no, treat medically
Stable pt/ trouvaille fortuite de pthx
treat conservatievely - no chest tube
RO relative contre indications
Rx (anticoagulant)
lab data (coagulopathy)
Allergie (to disinfectant or anesthesia)
Past Hx of pthx or lung surgeries (pleural adhesions)
Preparation - personal protective equipment
Sterile gloves
Sterile gown
Hair covering
Surgical mask
Preparation - desinfection and local anesthesia (5)
Sterilizer (chlorhexidine or povidone-iodine)
Sterile drapes
Local anesthetic (e.g., 1% Lidocaine - 10ml needed)
21-23 gauge needles; 1.5 inch
10 cc syringe
Preparation - instruments 8
2 Kelly clamps
Forceps
Needle driver or driver
Scalpel
Non absorbable suture
Chest tube (size is influenced by the indication)
Chest drainage bag (under water sealed)
Dressing gauze and tape
chest tube size units and examples small vs big
unit: French
greater number = bigger size of tube
24 Fr = 8mm in diameter
simple pthx = 18Fr or even a pig tail catheter
hemothorax = large >28Fr (minimizing risk of clot)
12 steps of the procedure
Positioning
Identifying the site
Precautions
Disinfect and draping
Local anesthesia
Skin Incision
Dissection
Digital exploration
Tube insertion
Connection and suturing
Dressing
Confirmation and reassessment
Where is the needle insertion
4th-5th ICS
ABOVE THE UPPER EDGE
avoid damaging the neurovasc bundle!
how big the skin insertion and what position
2-3cm parallel to the rib or horizontal
what’s the kelly clamp for
dissection
how do you know you have reached the pleura
pop sound
gush of air or fluid
how to hold the kelly clamp while dessecting
with two hands
for better control and avoid dammage
After reaching the pleura what do you do (hint: before chest tube insertion)
finger sweep
how to estimate the depth of the tube
place it on the person
10-14 marking at the skin after insertion
tube insertion - 2 important things
- close the tube with a kelly clamp (the side you are putting in) for guidance in a 45 ish angle
- close the open end of the tube (perpendicular) with the 2nd kelly clamp
indications for good insertion
fogging
fluid drainage
after insertion of tube when to open the 2nd kelly clamp
after connecting to a collection device
what to do after the sutures
apply a sterile dressing
confirming the right positioning
chest xray
monitor VS
monitor labs prn
Complications (7)
Organ damage (name any in the area)
Placement at incorrect site/subcutaneous placement
Subcutaneous emphysema
Infection at the site drainage site or empyema
Tube blockage or kinking
Dislodgement
Re-expanding pulmonary edema
Indications for resuscitative thoracotomy (4)
- Hemodynamic instability
- > 1,500 mL of blood drains initially upon insertion of chest tube
- Persistent bleeding of >200 mL/hr for 2 to 4 hrs
- Penetrating wound in anterior cardiac box
troubleshooting subcut emphysema
occurs when chest drainage is inadequate compared to the rate of the leak
- check if tube clogged or kinked /appropriately placed
consider: - increasing the suction on the tube
- replacement with a larger diameter tube
signs of blocked chest tube
- lack of fluctuation of fluid in the tube with breathing
- subcut emphysema
tube dsulodgement - wht to do
do not reinsert
need to put a new one
risk with rapid re-expansion of the lung
re-expansion pulmonary edema
dyspnea, descreased Sat
monitor drainage
