see: [Dunn management of pneumothorax](x-devonthink-item://6A784754-6907-461A-9FFB-C9910E7355D3), [Robert hedges tube thoracostomy](x-devonthink-item://31ACDC98-D2CC-48C5-BE69-E9B37E53FA8C?page=260), [Tintinalli - tube thoracostomy](x-devonthink-item://1ADC8D20-7826-44D0-9DEE-31D41057C9A3?page=72) > [!key points] > 1. [[Scalpel sizes|scalpel]] to SKIN; use kelly/robert clamps for *blunt dissection* and then pointing down over top rim of rib with finger a few cm from tip to puncture pleura > 1. \#10 is easier to cut with quickly; \#11 bit more precision of cut > 2. it can be REALLY hard to get through the pleura! This is an intimidating aspect of the procedure. may need more local in this area > 3. avoid the temptation to use a scalpel for this to avoid incision of a lung or intercostal vessel > 2. make the skin incision 3-4 cm > 3. insert 24 fr chest tube until *all the holes are inside the pleura* > 1. markings on chest tube are from last drain hole, NOT end of tube > 2. tube 8-10cm in for average person; 12cm larger chest > 4. probably safer to double glove > 5. ==avert the disaster of the tube coming out of the chest before you secure it== > 1. I clamp the drape around the tube to secure it (similar to how you secure the ETT tubing to the pillow with a clamp), and clamp the tube itself with a second clamp to prevent haemothorax from leaking > 6. chart some cefazolin afterwards (controversial) > > in the context of a [[Traumatic arrest]] just do [[#4. Pleural decompression|finger thoracostomy]] (aka pleural decompression) > **Aeshan's hot tip:** > recommend scalpel cut is ~4 cm. index finger generally around this size, so if cut is shorter than index finger, it is probably not long enough. ![[Pasted image 20240226003732.png]] ![[Pasted image 20241127091641.png]] ![[Pasted image 20241127071943.png]] # Overview ## Indication - tension [[Trauma/pneumothorax]] - [[Traumatic arrest]] - primary spontaneous pneumothorax in unstable patient un failed aspiration, very large PTx (complete lung collapse - all secondary spontaneous pneumothoraces - pleural lavage in management of severe [[Hypothermia]] ## Contraindications (relative) > there are no absolute contraindications to pleural decompression in the emergency setting, but there are several situations for caution and relative contraindications: - spont ventilation (for finger thoracostomy) - may create a sucking chest wound - tx occlusive dressing and formalisation to tube thoracostomy - significant [[Coagulopathy]] - may consider seldinger - presence of pulmonary bullae - CT can help guide management - presence of traumatic diaphragmatic hernia - Alert patient declines consent ## Alternatives - needle thoracostomy - small intercostal cathether with seldinger technique - large intercostal cathether (blunt dissection 24-32 Fr) ## Consent - no consent in emergency - Explain below complications otherwise ## Complications *immediate* - failure to decompress - pain - malposition (extrapleural, intrafissural, intrapulmonary, trans-diaphragmatic) - solid organ injury (lung, liver, spleen, colon) - trauma to [[Procedures#procedures and specific anatomical considerations|intercostal neurovascular bundle]] (long thoracic nerve, intercostal vessel injury) - tube impingement or kinking leading to failure to drain - haemorrhage - [[pupil exam#Horner Syndrome|Horner's syndrome]] *late* - infection (empyema) - pneumothorax re-accumulation - bronchopleural fistula - re-expansion pulmonary oedema - malpositioning (leading to damage to chest or subdiphragmatic organs) - kinking or obstruction with blood/clot, leading to failure to drain chest and risks of tension - dislodgement or migration out of chest leading to open pneumothorax - infection > [!pearl] structure for complications of x procedure > - **procedural complications** - eg damage to intercostal, lung contusion, liver injury > - **equipment complication** - tube kinking, malposition into fissure leading > - **post-procedure complication** - dislodgement, migration > - **late complications** - infection and empyema **underwater seal -- ?suction** - suction only if pt significantly compromised and lung not expanding -- no evidence of routine suction in spont ptx (some say after 48 hours) - suction starts at -10 to -20 cm H2O (normal intrapleural pressures are -8 to -3.4 cm H2O **indications for removal** - lung has re-expanded on CXR - no evidence of air leak - no suction in prev 6 hours - do not clamp at time of removal - remove preferably during expiration or when performing a valsalva - immediate closure and occlusion of the insertion site - repeat CXZR in 2-6 hours following tube removal and discharge if PTX completely resolved # Procedure ## 1. Position - below axillary hairline, between anterior and mid-axillary lines - lateral to pectoralis major and breast tissue - medial to latisimus dorsi in "triangle of safety" - 4th-5th intercostal space ![[Pasted image 20241127072018.png]] can also identify mid-humeral point btwn acromion and olecranon ## 2. analgesia and sedation generous lignocaine/adrenaline suspension ## 3. equipment - 24 Fr ICC - skin prep - [[Scalpel sizes|scalpel]] (#10 or #11, usually easier with a #10) - curved roberts or kelly forceps - 2x large tegaderms - size 0 silk suture x 2 - PPE including eye protection and double glove ![[Pasted image 20250307174137.png]] ![[Pasted image 20250307174222.png]] ## 4. Pleural decompression > when using kelly clamp to puncture pleura, a considerable amount of pressure may be needed. hold finger a few cm from tip of clamp and angle down over border of top rib ![[Pasted image 20241127074952.png]] ![[Pasted image 20241127075051.png]] - apply skin prep - infiltrate local anaesthetic to skin and then down to pleural space (may aspirate air to see you are in the right space; can then infiltrate local into pleura as well) - skin incision 3-5cm long over 5th rib - blunt dissect in oblique plane through intercostal muscles over superior rib margin using curved roberts forceps - the oblique direction helps close the tract after removal to prevent re-accumulation pneumothorax - open forceps in AP direction then rotate to enlarge pleural breach - finger sweep of cavity to ensure no adhesions - ==if you feel the lung you get to shout "Lung is up!" triumphantly to the resus room== ## 5. ICC insertion ![[Pasted image 20241127082552.png]] - insert ICC through lowest point of intercostal space - run along surface of finger to prevent intrapulmonary insertion - orient *apical-posterior* for pneumothorax - *basilar-posterior* for haemothorax/haemo-pneumothorax - 3-4 cm beyond last drainage hole in pleura - usual insertion length ==8-12 cm== (more in obese patients) - once inserted, rotate 360 deg to reduce risk of kinking ![[Pasted image 20250307174417.png|inserted 10cm into chest in this non-obese adult]] ## 6. Secure the ICC - use 0 silk and place vertical mattress on superior side of drain, tying a locked knot. use remaining suture to wrap around tube close to skin and secure with another locked knot that bites the tube - repeat for inferior side of tube - do **NOT** "roman sandal" tie; make the ties proximal to the skin and give a tug after finishing to ensure it is actually secure - cut a gauze to pad over entry site of tube - place two large tegaderms using a sandwich - after attaching underwater seal drain, secure drain on a mesentery to abdominal wall using sleek tape - Wrap sleek vertically around connection between drain and ICC , leaving a window to ensure no blood clots occluding drain ## 7. underwater seal drain ![[Pasted image 20241127090237.png|The "atrium"]] The atrium has 3 chambers: - D - collects fluid or blood drained from pleural cavity - C - underwater seal drain. prevents air from being pulled into pleural cavity. ==this chamber always has 2cm of water in it== - A - suction control chamber. allows suction to be applied and is used when a greater negative intrapleural pressure is needed to drain a large volume or persistent pneumothorax - generally in the acute setting of trauma leave this off Air leaks can be measured by looking at the markings in the underwater seal chamber (c) ![[Pasted image 20241127091608.png]] **Set up** - fill water seal with 45mL water to 2cm line - fill suction control chamber to desired level (460mL for -25cm H2O pressure; 315 mL for -20 cm) - connect patient catheter - +/- connect to suction source - clamp tube then cut blue nipple cover on outer end of tube - ensure drain is bubbling and swinging can use **heimlich valve** in interim eg transport ![[Pasted image 20241127091449.png|Heimlich valve. ICC connects to the top end of the valve; a drainage bag or connector can be attached to the bottom]] # Troubleshooting see also: [[Peri-intubation collapse#troubleshooting post-intubation hypoxia or hypotension|post-intubation troubleshooting]] **Drain stopped swinging** - has the lung re-expanded - is the tube kinked or blocked? - is lung tissue blocking tube during expiration? check tube placement on CXR **patient deteriorates** eg hard to ventilate, EtCO2 going down, hypotensive - blocked tube, circuit, or kinking -- can cause tension pneumothorax in presence of ongoing air leak - is suction tubing attached to suction limb? if the suction tubing is not switched on this can create a closed circuit and causes tension in presence of air - is there worsening s/c emphysema? check if drainage holes have migrated outside pleural space or if the drain is blocked - check for tube displacement > when in doubt, re-sweep the chest.