Thoracostomy – blunt dissection technique

Indications

  • Pneumothorax
    • Consider using a smaller catheter inserted via seldinger technique for small uncomplicated pneumothoraces
  • Haemothorax

 

Contraindications

  • Drain not indicated or there is an alternative method of insertion (see above)
  • Patient is anticoagulated or has a bleeding diathesis
    • A relative contraindication only
      • If a patient is in extremis or in cardiac arrest – perform thoracostomy
      • If patient is “stable” then consider reversal of anticoagulation prior to procedure

 

Equipment

Many departments will have pre-prepared thoracostomy packs

 

  • PPE
    • Gown, gloves, mask, eye protection
  • Drapes
  • Antiseptic solution
    • Eg: betadine or chlorhexidine
  • 1% lignocaine (with or without adrenaline) 10-20ml
    • 10ml syringe for LA
    • Drawing up needle
    • 25G needle for skin infiltration, 22G needle for deeper infiltration
  • Scalpel
  • Curved forceps
  • Chest drain
    • 28-32F (adult)
      • note: there is increasing evidence that smaller drain sizes can be sufficient in many trauma patients. In patients with a simple pneumothorax, consider using a smaller drain inserted via seldinger technique.
    • Underwater seal drainage kit
    • Silk 1.0
    • Suture equipment (forceps, scissors, needle holder)
    • Dressings
      • Tegaderm, tape, gauze

 

Patient preparation

This can be a painful procedure even with adequate local anaesthetic infiltration

Pretreat patients with IV opiate analgesia

Consider procedural sedation (eg: ketamine)

 

Consent

If patient is conscious and competent: obtain (written) consent ideally. Some severely injured patients may only be able to give verbal consent.

If patient not consentable – proceed provided it is clearly in the patient’s best interests

See Code of Right – Right 7 (4)

http://www.hdc.org.nz/the-act–code/the-code-of-rights/the-code-(summary)

 

 

Procedure

  1. Position patient
  • If conscious and cervical spine cleared – sit patient at 45 degrees
  • Abduct ipsilateral arm to 90 degrees and place hand behind head

 

Use a towel or sheet to secure arm in place for procedure

 

  1. Mark site of insertion
  • 4th or 5th intercostal space in the anterior axillary line

 

The “triangle of safety”

Anteriorly: lateral border of pectoralis major

Posteriorly: anterior border of latissimus dorsi

Inferiorly: 5th intercostal space

 

Reproduced with permission from http://www.oxfordmedicaleducation.com/clinical-skills/procedures/intercostal-drain/

 

The 5th IC space equates to around the nipple line in male

  • If in doubt, go a space higher

If the patient has a penetrating chest injury, do not place drain through this hole, make a new one adjacent

 

  1. Don PPE
  •   Gown, gloves, mask, eye protection

 

  1. Aseptic technique
  • Clean area with antiseptic solution
  • Place drapes

  Note  – if patient is periarrest or in cardiac arrest, strict asepsis might not be feasible

 

  1. Infiltrate with local anaesthetic
  • First the skin, then proceed to infiltrate deeper through intercostal muscles and then pleura
    • If patient has a pneumothorax – will aspirate air when through pleura
    • May aspirate blood with a haemothorax (depending on degree of coagulation)

 

  1. Incise skin
  • Make a transverse 2-3cm skin incision directly over the inferior rib (ie: 5th or 6th rib)
    • The aim is then to proceed above and over this rib

 

  1. Blunt dissect
  • Through intercostal muscles using curved forceps
  • Aim to go OVER the rib to avoid the neurovascular bundle
  • Pierce the pleura
  • Signalled by a rush of blood in haemothorax or whoosh of air in pneumothorax

 

Brace the hand holding the distal end of the forceps against skin to prevent plunging into pleural cavity

Open the forceps once inside the pleural space to create a hole large enough for drain placement

 

  1. Place finger inside pleural cavity and “sweep”
  • Ensure you are inside the correct space and not abutting diaphragm or intraperitoneal contents

In traumatic cardiac arrest, it is acceptable to decompress the chest to this point and not place a chest drain immediately. If ROSC (return of spontaneous circulation) is obtained, a formal drain will need to be placed.

 

  1. Place chest drain
  • Grab the tip of the chest drain through one of the drainage holes with forceps to guide drain into space

If you are in the correct location, it should slide in “like a rat up a drainpipe”

Aim drain cephalad for a pneumothorax and caudal for a haemothorax

Don’t use a trocar, this can cause serious injury to underlying structure

 

  1. Connect drain to underwater seal
  • For a pneumothorax – ensure drain is “bubbling” and “swinging” (rise and fall of underwater seal)
  • For haemothorax – blood will drain

 

Place brown tape over all drain connections to prevent accidental detachment

 

  1. Suture drain to skin and place dressings

 

  1. CXR
  • Confirm correct position

 

Here is a video of the procedure (performed on a mannequin)

 

Complications

  • Early
    • Pain
    • Bleeding
      • Bleeding from intercostal vessels is non-compressible and can be catastrophic. Avoid by blunt dissecting and aiming up and over the rib
    • Incorrect placement into subcutaneous space
    • Damage to underlying structures
      • Lung, heart, intraabdominal contents
  • Late
    • Drain blockage
    • Drain displacement or dislodgement
    • Infection/empyema
    • Persistent pneumothorax or recurrence of pneumothorax after drain removal
    • Scarring

 

About this guideline

Published: February 2018

Author: Emma Batistich

Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB

Review due: 2 years