CTT Flashcards
Things to know in CTT insertion
A. Preparation of materials
B. Preparation of the patient
C. Placement of chest tube
D. Hooking to drainage system
E. Monitoring
F. Troubleshooting
Materials for CTT
- Prep solution
- Local anesthetic
- Scalpel
- Large Kelly clamp
- Chest tube
- Suture (1-0 silk) and dressing
- Drainage system
How to prepare the patient
- Position
- 30-60 degrees head elevation (to lower diaphragm and decrease the risk for injury to the diaphragm, spleen and liver)
- raise arm with hands behind the head - Monitoring
-
Site identification
Inframammary crease in women - 5th ICS
10 steps in chest tube insertion
- Don PPE
- Disinfect and drape
- Anesthesize
- Incise
- Blunt dissection
- Puncture of parietal pleura
- Verification of parietal pleura penetration
- Chest tube insertion
- Verification of chest tube insertion
- Suture, dress, and secure
How to anesthesize
Anesthesia is the 3rd step
Use general local anesthesia, such as up to 4 mg/kg of locally injecteed 1% lidocaine with or without epinphrine
(max of 5 mg/kg of lidocaine)
What to do while waiting for anesthesia to take effect?
- Premeasure the estimated depth of chset tube by placing the tip near the clavicle with a gentle curve of chest tube toward the incision
- Place a clamp on the tube to mark the maximum length that the tube should be inserted
- Load blade
How to perform skin incision
Skin incision is the 4th step
1. Make a 2-3 cm (ATLS) or 3-5 cm (Roberts and Hedges) oblique incision following the orientation of the ribs
2. Make the incision 1-2 cm below the interspace through which the tube will be placed (Tintinalli)
3. Use a No. 10 blade
3-5 cm is 2-3 fingerbreadths
What is the 5th step in chest tube insertion?
Blunt dissection
Remarks in puncturing the parietal pleura
Puncture of the parietal pleura is the 6th step
1. This is the most painful part, so an additional injection of local anesthetic may be done
2. Hold the kelly clamp near the tip to prevent sudden deep insertion and injury to underlying structure
3. Considerable force may be needed.
4. A pop will be heard, with gush of air or pleural fluid
5. Enlarge the hole to at least 2 cm, but avoid a large opening to reduce the risk of air leak
Remarks on verification of pleural space penetration
- Slide a sterile gloved finger over the clamp and into the pleura before withdrawing the clamp
- Leave the finger in the pleural space to ensure that the hole is not lost
- Make a 360-degree sweep to verify the correct space, to feel for adhesions, to clear clots
Remarks on the actual insertion of chest tube
Chest tube insertion is the 8th step
1. direction:
- pneumothorax: toward the apex, away from the hilum and mediastinum
- hemothorax - toward the posterior and lateral
- The tube should pass with little resistance, otherwise it may be passing subcutaneously, is in a fissure, or is abutting against the mediastinum
- Rotate the tube 360 degrees to reduce the likelihood of kinking
- Advance tube at least until the last side hole is 2.5 to 5.0 cm inside the chest wall, or until the previously placed clamp from the premeasure has reached in the insertion site
How to verify chest tube insertion into the pleural space?
Fogging
Listen for breath sounds
Remarks on suturing the tube
- Use 0 or 1-0 silk or nylon sutures
(Nylon sutures are acceptable but must be tied tightly or they will slip on the surface of the tube) - Tie the sutures tightly enough to indent the chest tube slightly and avoid slippage
Methods of suturing
Stay suture
Horizontal mattress suture
How to dress chest tube
Place an occlusive dressing of petrolatum-impregnated gauze.
Place another dressing at 90 degrees to the first
