Tube Thoracostomy Insertion

Tube Thoracostomy Insertion

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This high quality video demonstrates tube thoracostomy insertion on a live patient. One of the most commonly performed hospital based procedures, chest tube insertion is shown step by step. Clinical pearls and common pitfalls associated with chest tubes are discussed in detail.  The video is not downloadable but may be accessed indefinitely by internet from any computer, smart phone, or tablet.  Click below to preview the Tube Thoracostomy video.

 

This is a thoraseal container with three compartments. We are currently filling up the water seal compartment to the designated line. The far right-hand compartment is the suction compartment filled up to 20 centimeters of water, the water seal compartment is filled up to the designated line, and then the drainage compartment is connected to the patient via the chest tube.

Time out procedure is taken to confirm the correct patient, correct procedure and correct side. Now, we are doing a betadine prep. As you can see the patient is positioned in a semi-upright position with ipsilateral arm secured over the head. 

1% lidocaine is used for local anesthesia. And now a sterile drape is applied to the side of the procedure. 1% lidocaine is used to anesthetize the skin here in the fifth intercostal space of the mid-axillary line. Also used to anesthetize the underlying soft tissue in the periosteum of the rib superior to the skin incision.

Since this procedure can be potentially painful and in a semi-elective procedure it is advisable to transfer the patient to a monitored setting where procedural sedation can be administered. In this case the patient was transferred to a monitored bed and sequential doses of 2 milligrams of morphine and 2 milligrams of versed were administered to keep the patient comfortable.

Here a scalpel is used to make a 3 centimeter skin incision parallel to the ribs in the fifth inter-costal space. 

Blunt dissection is carried out with a curved Kelly clamp over the rib superior to the skin incision and through the intercostal muscles. 

If at any point, the patient feels a discomfort, administer more local anesthesia directly into the skin incision, the Kelly clamp is now used to puncture through the pleura, the clamp is spread wide to extend the pleural opening and then withdrawn. 
A finger is then used to sweep free any pleural adhesions and to confirm entrance into the pleural cavity. A chest tube is then introduced using another curved Kelly clamp until the pleural space is entered, the Kelly clamp is then released and the tube is gradually advanced until the desired depth of insertion is reached.

The tube is then secured with a stay suture. Here the suture is seen to be wrapped sequentially around the tube to secure it tightly. This can be carried out on both sides of the tube, as is shown there. 

Vaseline Gauze is then used to wrap around the tube and seal the skin insertion site. Sterile gauze is put underneath the tube and then the tube is secured in place with tape.