Chest tube insertion

Question 1

4 indications to insert chest tube for different types of pneumothorax

Answer 1

Tension pneumothorax
Recurrent and persistent pneumothorax
Bilateral pneumothorax
Pneumothorax on positive pressure ventilation

Question 2

5 other indications

Answer 2

Hemothorax
Empyema
After cardiac and lung surgery
Chylothorax
Malignant effusion

Question 3

Relative CI

Answer 3

Coagulopathy
Skin infection over the site of incision
Past history of lung surgery or lung disease
Allergy to sterilizer and local anesthesia

Question 4

phgy dehind cardiac instability in pthx

Answer 4

compression of the vena cava and no blood return

Question 5

VS pthx

Answer 5

tachycardia
tachypnea
hypota

Question 6

ultrasound findings

Answer 6

no lung sliding in normal mode
barcode sign - parallel horizontal ligns in M mode

Question 7

Site for needle decompression

Answer 7

4th or 5ht intercostal space (memlon ish) between ant and mid axillary line

Question 8

signs of tension pthx (6)

Answer 8

dyspnea
absent or decrease breath sounds
tracheal deviation
subcut emphysema
hyperresonance
unstable VS (hypoTA, tachycardia, tachypnea)

Question 9

signs of hemothorax

Answer 9

dyspnea
decreased breath sounds
DULLNESS to percussion

NOT tracheal deviaiton

Question 10

Empyema risk factors (6)

Answer 10

immunocompromised pts
diabetes
receiving immunosuppressants
steroid use
chemotx
ROH and IV drug users

Question 11

chylothorax cause

Answer 11

thoracic duct injury (milky white effusion)

Question 12

pleural effusion from CHF - do you put a drain

Answer 12

no, treat medically

Question 13

Stable pt/ trouvaille fortuite de pthx

Answer 13

treat conservatievely - no chest tube

Question 14

RO relative contre indications

Answer 14

Rx (anticoagulant)
lab data (coagulopathy)
Allergie (to disinfectant or anesthesia)
Past Hx of pthx or lung surgeries (pleural adhesions)

Question 15

Preparation - personal protective equipment

Answer 15

Sterile gloves
Sterile gown
Hair covering
Surgical mask

Question 16

Preparation - desinfection and local anesthesia (5)

Answer 16

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

Question 17

Preparation - instruments 8

Answer 17

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

Question 18

chest tube size units and examples small vs big

Answer 18

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)

Question 19

12 steps of the procedure

Answer 19

Positioning
Identifying the site
Precautions
Disinfect and draping
Local anesthesia
Skin Incision
Dissection
Digital exploration
Tube insertion
Connection and suturing
Dressing
Confirmation and reassessment

Question 20

Where is the needle insertion

Answer 20

4th-5th ICS

ABOVE THE UPPER EDGE
avoid damaging the neurovasc bundle!

Question 21

how big the skin insertion and what position

Answer 21

2-3cm parallel to the rib or horizontal

Question 22

what’s the kelly clamp for

Answer 22

dissection

Question 23

how do you know you have reached the pleura

Answer 23

pop sound
gush of air or fluid

Question 24

how to hold the kelly clamp while dessecting

Answer 24

with two hands
for better control and avoid dammage

Question 25

After reaching the pleura what do you do (hint: before chest tube insertion)

Answer 25

finger sweep

Question 26

how to estimate the depth of the tube

Answer 26

place it on the person 10-14 marking at the skin after insertion

Question 27

tube insertion - 2 important things

Answer 27

1. close the tube with a kelly clamp (the side you are putting in) for guidance in a 45 ish angle 2. close the open end of the tube (perpendicular) with the 2nd kelly clamp

Question 28

indications for good insertion

Answer 28

fogging fluid drainage

Question 29

after insertion of tube when to open the 2nd kelly clamp

Answer 29

after connecting to a collection device

Question 30

what to do after the sutures

Answer 30

apply a sterile dressing

Question 31

confirming the right positioning

Answer 31

chest xray monitor VS monitor labs prn

Question 32

Complications (7)

Answer 32

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

Question 33

Indications for resuscitative thoracotomy (4)

Answer 33

1. Hemodynamic instability 2. >1,500 mL of blood drains initially upon insertion of chest tube 3. Persistent bleeding of >200 mL/hr for 2 to 4 hrs 4. Penetrating wound in anterior cardiac box

Question 34

troubleshooting subcut emphysema

Answer 34

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

Question 35

signs of blocked chest tube

Answer 35

- lack of fluctuation of fluid in the tube with breathing - subcut emphysema

Question 36

tube dsulodgement - wht to do

Answer 36

do not reinsert need to put a new one

Question 37

risk with rapid re-expansion of the lung

Answer 37

re-expansion pulmonary edema dyspnea, descreased Sat monitor drainage