Tube thoracostomy

Steps

1. Appropriately position the patient (ipsilateral arm up and behind head).

2. Administer anxiolytics/analgesia or sedation as indicated.

3. Sterilize the field. Appropriately drape the area and don sterile gloves, gown, mask, and eye protection per universal precautions. .

4. Identify landmarks (fifth rib; triangle of safety is the border of the pectoralis anteriorly, latissimus dorsi posteriorly, nipple line or infra-mammary fold inferiorly).

5. Identify insertion site (within the triangle of safety, anterior axillary line, in 5th intercostal space).

6. Generously administer local anesthetic. Infiltrate superficial and deep tissues. Aspirate to avoid entry into a vessel prior to injecting.

7. Use a scalpel to make a transverse 3-5 cm incision overlying the rib located below the insertion site.

8. Use a Kelly clamp to bluntly dissect over the rib to avoid the neurovascular bundle. Firm resistance will be felt when the parietal pleura is met.

9. Close the clamp and puncture the pleura. Brace the clamp with your non-dominant hand to prevent over-insertion. With the tip of the clamp in the pleural cavity, spread the clamp to make an adequate hole in the pleura.

10. Slide one finger over the clamp and into the pleural cavity. Verify palpation of the lung or pleural space. Be cautious of any broken ribs.

11. Withdraw the clamp.

12. Pass the tube alongside your finger and into the pleural cavity. Remove your finger. Direct the tube posteriorly, medially, and superiorly until the last hole of the tube is clearly intrathoracic or resistance is felt.

13. Attach the tube to the previously assembled chest tube drainage system.

14. Suture the chest tube to the skin, and cover with an occlusive dressing.

15. Secure the tubing to the flank with a mesentery tape to act as a strain relief.

16. Order a chest x-ray to confirm placement.