Page 194 - 2023 SMOG Digital

SIMPLE (FINGER) and TUBE

THORACOSTOMY

CLINICAL INDICATIONS:
• Pneumothorax + positive pressure ventilation or interfering with oxygenation
• Hemothorax + positive pressure ventilation or interfering with oxygenation
• Chest injury with suspected pneumo / hemothorax as above
• Evidence of tension pneumothorax after needle thoracostomy attempts
CONTRAINIDICATIONS:
• Stable patient oxygenating well, no tension PTX
• Blood clotting abnormalities (relative)
PROCEDURE (STERILE):
• Ensure all equipment prepared / available: Scalpel, 4X4 gauze, petroleum gauze, suture material
(0-1-0 silk), 28Fr or larger chest tube, Heimlich valve/Water seal, large Kelly clamp x 2, betadine/skin
cleanser, 1-2% lidocaine, 10mL syringe with needle for lidocaine, sterile gloves.
• If possible, position patient supine with shoulder flexed up and hand under his/her head.
• Identify and clean area of insertion with skin cleanser. Area of insertion should be over the 4 th or 5 th rib
(3 rd or 4 th intercostal space) on injured side.
• If possible, with conscious patient, anesthetize the area with lidocaine. Take care to anesthetize the rib
by passing needle perpendicular to skin until bone contacted and backing off slightly to inject lidocaine.
May also anesthetize the pleura by advancing needle just until air returned and then injecting area while
pulling back needle.
• Make incision in skin/SQ tissue overlying 5 th rib. Ensure incision large enough for insertion of tube/
finger (approximately 1-2 inch).
• Bluntly dissect tissue going over 5 th rib with second clamp until pleura is reached, then puncture the
pleura with the clamps. Prevent overly deep insertion by using non-dominant hand to guide insertion or
holding clamps in hand with index finger on shaft of the instrument.
• Open clamps as wide as possible to enlarge the pleural opening and remove clamps. Blood and/or air
may present at this time.
• Place finger into opening and palpate for any adhesions.
o If Simple Thoracostomy ONLY, place vented chest seal over opening and position patient on
ipsilateral side (if possible) and monitor for signs of tension pneumothorax.
o If proceeding to tube placement, continue below ensuring tube is clamped closed on distal end
before insertion.
• Advance tube into opening directing the tip of the tube posteriorly and superiorly towards the lung apex
along the posterior aspect of the chest wall, ensuring all fenestrations are moved into opening. This
method ensures tube will drain both hemo and pneumothoraces.
• Holding tube in place – Pad under tube with Kerlix and place modified chest seal around the tube
ensuring seal of the wound and securing tube in place. If possible, stitch or staple tube into place.
• Apply suction to tube / Heimlich valve and remove clamp.
Document procedure, results, and vital signs.
CHEST TUBE TROUBLESHOOTING:
• Ensure tube not clamped / kinked and that suction is working.
• Ensure tube has not become dislodged.
• If evidence of tension PTX–remove attachments from end of chest tube (e.g., suction adapter, Heimlich
valves, suction devices) to convert to open PTX. Troubleshoot attachments and re-apply if appropriate.

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