Chest Tube Placement for Possible Hemothorax
A hemothorax is a collection of blood within the pleural cavity. Blood can accumulate within the pleural cavity due to many causes such as: chest trauma (penetrating or blunt), thoracic surgery, or aortic disease. To treat the condition, a thoracostomy tube is inserted into the thoracic cavity on the diseased side of the body. In addition to blood in the pleural cavity, a chest tube can also be used to treat pneumothorax (air in the pleural space), pleural effusion (empyema, chylothorax), and insertion of medications. Depending on the need, a tube or catheter (14 fr. or smaller) may be used.
Table of Contents
- Local Anesthetic
Okay, so first thing you want to do is make sure that the patient is appropriately positioned. So you have her right arm up in extension so that hopefully the rib spaces are nice and wide for you. You want to make sure that her arm is secured so that if it's you by yourself you don't have to worry about her arm coming down. Especially, you know, while you're doing your procedure or if she's uncomfortable or anything like that. And then after she's appropriately positioned then you want to prep your field out so that you're ready to go. The kit usually includes a prep as well, but I usually just prep beforehand so that I know everything that I want to be in the field is already done. And then for the drape I usually cut a little bit of a window for the nipple since often we use the nipple as a landmark, especially in trauma where you just want to make sure you're in the right area. So for her, her breasts aren't like super pendulous so we can use her nipple as a landmark. Obviously like if the nipple was all the way down here, we're not going to use the nipple. So I would aim for lateral to the nipple, and then you want to be in like your safety triangle so in this space bordered by your pec, your lat, and your axilla. So I - felt a little bit - we'll have to make a, you know, skin incision and kind of divide down, but I think if we go about here… Sorry! We should be okay. So we need to just make sure and numb her up well and then we can also use the Ketamine after we've used our Lidocaine.
So with the drape I would cut a hole or like a little extension so that when the drape goes on you can see the nipples as a landmark and then after we're draped, we can start our local. So you can go ahead and use the scissors to cut a little window. Usually if it opens this way, then you want to cut the extension like here. Perfect, and then I just kind of like rip this off. So then when you take off your sticky, make sure this is like where the nipple is and then everything else is, you know, this safety triangle where we're going to put the tube in. Sticky application. You're going to feel the drape over you, okay ma'am? Okay. Drape over you, okay ma'am? Great, perfect. So I think we can probably even come a little bit towards us with the drape because our space is a little bit more - Yeah, great. So maybe even… So, like so. Because we're going to aim for about this spot right here, okay? See - that the ribs are sensitive, so - okay.
So just since she has a little bit of extra soft tissue there, you can kind of mark out where you're planning to put your incision. That way we don't get lost. Okay.
So first thing is you want to make sure she's comfortable, we gave her little bit of Fentanyl to kind of relax her. We have Versed ready for when we actually do like the - when we get into the pleural cavity, but first we can start by numbing. So remember to raise your wheel first along where you're going to make your skin incision. Okay. And that needle may not be long enough, actually. So this is the needle that we use here. See how nice and long this is so we can actually get into the chest with this. Okay ma'am, you're going to feel a poke and a sting, okay? Poke. Sting. Okay. Remember to save like most of it for actually the chest - pleural space. Okay, another poke. So if you can here, you can give her a little time too, for the medicine to kind of kick in. But you want to be like perpendicular to the chest, You want to try and see if you can - when you go in, find the rib. Poke. And then you want to be on the top of the rib, not under the rib, right? Because our neurovascular bundle is on the bottom, so once you identify a rib, you want to see if you can get in on top of it and then enter the pleural cavity if possible and see if you can aspirate either air or blood. I think there's air, not blood. And if you can't, that's okay. You do have air? I have some air in the vault, but… If you're in the chest cavity and you aspirate, air should fill and you shouldn't get suction back. Okay. No. Sometimes it can be a little tough when patients are deep. Okay, I don't have air. And you can just - may I take a feel just to see how deep you are here? Another poke here, okay? So I'm right on the rib. Just push, just feel that. It's a very light - see how that's hard right there? So then when you're on the rib, you angle just a little bit, so you kind of walk it up the rib to where now - now I think I'm in the chest now. And so I can pull air. And I'm going to inject a bunch of local right here. Because this is where she'll have, like, the most tenderness. So I'm putting it all like right outside of the chest wall where we're going to come through. So that way, hopefully she'll be as comfortable as possible. And then usually I will ask for more local. That way if we need it, we have it. But we can see how we do, and then you know we have the Ketamine also.
Okay, so next you can make your incision, and I would recommend you probably extend this maybe by another centimeter. So we have like a 3 cm incision, we can always close it, but we don't want to be struggling. And she's a little deep, so… Okay. And remember, it's a stab and then pulling in the direction of the blade. Is that feeling sharp? Yes, it is. Okay, one second. Should I stop and numb her some more? Yeah, just stop for a second. May we get a little bit more local, please? Yes. Okay, I think it's because - of that extension of the incision. So I'm just going to give a little bit more here. I'm going to give you a little bit more numbing medicine, okay? A little poke here. Okay. All right, so you can test too, by poking her and making sure it's more dull than sharp. Okay, let us - perfect, thank you. Let us know if you have any more pain, okay? Sure will. You're doing great. So remember, it's a stab and then pull up, and as you pull up… So kind of like this. Like a - let me show you. So it's - in and then up, like that. Okay, yeah, I would extend a little bit - like a little bit farther down. Okay, good. Perfect. All right, so protect your knife. And then since we're on the right side we don't have to really worry so much about the heart.
So you can use your hemostat and spread. And remember you want big spreads in the same space. Doing okay? Yes. Okay. Okay, and then you should be feeling - when you get down to the rib. Let me take a feel. So you can take that out for when we take a feel. Good, so you're almost there. Maybe give her the Ketamine. 30, right? Yep. So we can feel - I think you're spreading a little posterior but you want this area pretty open. But you're almost there, you can feel it really well. See that there's like a little pocket there. So try and go to like, the deepest spot where you already have a pocket and spread wide in there. Your spreads are really tiny. Yeah. And see she's doing okay, right? The numbing is probably working really well. You doing okay? Yes. Great. All right, we're going to give you some of that relaxation medicine, okay? We're almost done with the procedure. I'm on the rib. Great, let me take a feel. Good. So again, make sure you're right over it. I think if you - I think it'll pop right in, but let's get our tube set up. And then remember what we're going to do is once you're in with this, you want to make sure you spread nice and wide so you don't lose your spot and then you can pass me the large clamp, and I'll put it on your tube for you, and - you want to make sure when - I'm just going to demonstrate real quick. So when you go in, you want to go in over the rib, and then once you're in, then you want to rotate so that your tube goes against the chest wall. So once you're in, don't keep feeding it in because it may get cause in like, a fissure or something. So then you're in and then you want to twist it and rotate it so that it will go to the apex and also like against the chest wall. And then we have small fingers so sometimes once it's in in good position, it should slide pretty easily. But you can also confirm with another finger once it's in. Okay. Okay? And then make sure you tell the patient - a lot of pressure, And you know, we have her on the monitor, she has the Ketamine. Finding my hole. Okay. And then I usually use quite a bit of force - two hands. Just feeling for my rib space, which is right here. All right ma'am, you're going to feel some pressure. Just finding my rib space, which is here. All right, and some pressure, okay? Really push. Okay. I'm right on the rib, I think I'm a little posterior. So I usually have to lean my weight into it because… And push. And I'm - I'm in. You're in? Okay, spread really wide then with two hands. And just spread with the instrument, you don't have to use your finger if you're in the space. Good. Okay. And then if you want to confirm that you're in. Okay, can she take deep breaths? She's on 4 L. Is she following commands? I'm just spreading. Okay, if you're in, then we can put the tube in. Let me just take a feel. Okay, my finger is in it. Okay. I might have to expand it a little bit more. Okay. And, here my finger's in. Do you want me to move my finger? Okay. Yeah. You can - let me see. I don't know if you're in yet. I don't think you're in, I think you're - just along the ribs. So you're almost in, but there's a nice space here. So if you just give a lot of pressure here you should pop in. So pop in with the instrument closed and then once you're in, then you spread it. All right, some pressure. I felt the pop. Okay, now spread really wide with two hands. Now you're in, see there's all that fluid that's coming out, great. So it's all clear, so we'll make sure and dictate that in our report. And spread really wide so that when you come off your instrument you don't lose that spot. Okay. Spreading, spreading. my finger's in the hole. Okay. Do you feel like it's a good-size hole, we won't lose the spot? I think it's a good size hole. Okay, let me take a little feel. We can take this out real quick. I agree, it's a good-size hole, you can feel her lung.
So - I think we should be able to get this in well. So, this is… Okay, right here? Okay. So try not to, you know, once you know where your spot is, go in right on top of the rib, once you're in, then you just rotate and guide it along the chest wall and superiorly. So it's kind of a posterior/superior tube. And if you need help, I can help you too. Okay. Okay. I feel like I have resistance in advancing. Okay. Would you mind feeling for me? Sure. Let me - I can put it in, and then I'll let you… Okay. So I just spread with my fingers a bit. So then… May I feel where you are? Mm hmm, one second. Okay, so it's in now. So you're right over the ribs, so rotate. Okay, rotate. And then once you've advanced just a little bit, then take your clamp off. And then you should rotate the tube, it should slide fairly easily. To 20? And I usually put it at, actually like 14. We can always pull it back, but - so this is actually more like 16. And then you can ask the nurse to help pass you the end of the Pleur-evac. May we have that Pleur-evac, please? Yes. And then you want to connect your tube. And once you're connected, then you can take this other clamp off. Okay. Good, so take this off. Good, now we're getting nice, clear fluid which matches with what we saw on the scan.
So now you want to secure your tube. We'll do an interrupted stitch and then we'll do our U-stitch. And be careful not to stick yourself. Sometimes I use one of the clamps as like a DeBakey. And you always want to make sure you don't nick the tube also. So you can use… Oops, sorry. Is the needle okay? The needle's okay. So use the - yeah, kind of as a DeBakey. It's a little non-conventional, but I just don't want you to stick yourself. And, I'll get my needle. I'm just going to pull this out. You can take it in two. You're doing great. Good. Before we close, let me just take a feel and make sure this is like along… Yeah, so this is nice, flush along the thoracic wall. It's not in - doesn't feel like it's in a fissure, but we'll get her X-ray in a second just to see. It's a benefit of having small fingers, you can fit them in. And then leave yourself enough length so we can do the U-stitch too. Maybe one more. Let me get the scissors. Okay, and then so our U-stitch - do you remember how to do this one? Like an interrupted? I can help if you don't. I can show you. If that's helpful. Okay, so for the U-stitch. So… This should be here. So we'll go - in. And then out. I do fairly deep bites because I don't want this tube to go anywhere. And then you come back the same manner but it's a U, so - in - And then out. Okay. And I always cut off my needle so we don't worry about that when we're securing the tube. And that needle is protected. Let me get rid of all of these things. So then, so that one on the floor, whoever is pulling it is set up, you throw one throw, kind of cinch that down around the tube, and then that's it because if you throw another one then it's locked in. Then you can wrap around your tube here like a gladiator sandal, but see how it's cinched down nicely already, so it's kind of air-tight there? Then after that you can tie your knot. Okay, and then we'll cut. Then we're done. So obviously we'll clean off her chest, secure our tube, and we'll get our a chest X-ray and make sure we have good placement. And we'll document, you know, serosanguineous output from her chest tube.
I think just one should be adequate. Maybe one up here, and then we'll do one to secure the tube. And then you can make you're little "mesentery" with this piece. Just right over the middle? Like on the actual tube and then tape the tube to her skin so you kind of pinch it a little bit. Okay. That way the tube isn't, you know, dangling around. You can probably put a little bit more because that can be fairly uncomfortable, so… Under? Or Over? Yeah, or a little bit lower, so like it stays on her skin there.
Take a deep breath in. Hold it. Breathe.