Clinical intercostal spaces

Question 1

Patient comes in with a suspected pleural effusion. Where do you insert a chest drain?

Answer 1

chest tube insertion:

• medial: pectoralis major
• lateral: latissimus dorsi
• inferior border: 5^th ICS space

*important to insert it lower in ICS space to avoid neurovascular bundle

Question 2

Patient is set to have a thoracotomy surgery done and you are asked to give analgesic. How would you perform an intercostal nerve block? What are the important consequences if you puncture the intercostal artery/vein or parietal pleura instead?

Answer 2

• Intercostal nerve block*
• -under ultrasound guidance, find intercostal nerve in subcostal groove between the innermost intercostal muscle and inner intercostal muscle and inject local anaesthetic.*
• -consequences:*
• -haemothorax- pierce through intercostal artery/vein*
• -pneumothorax-pierce through parietal pleura*

Question 3

What are the different surgical procedures to gain access to the chest?

Answer 3

• surgical access to chest:*
• -for heart: midline sternotomy*
• -for lungs and mediastinal structures: thoracotomy through insertion in ICS space*
• -VATS (video-assisted thoracic surgery)can be done through small incision in ICS space-> camera instrument inserted via small ports->lower risk of infection and greater chance of healing*