Thoracostomies

Indications generally include: 1. Pleural collections/effusions 2. Pneumothoraces 3. Endocavitary drug administration 4. Traumatic cardiac arrest

Percutaneous pigtail thoracostomy

Resources

1. Pigtail Insertion for Pneumothorax - YouTube
2. Chest tube insertion – Pigtail | Department of Emergency Medicine | Saint John
3. Pigtail Catheter Placement for Traumatic Pneumothorax - YouTube
4. Ultrasound Guidance for Pleural-Catheter Placement | NEJM

Location

• Complications of Pleural Procedures > Triangle of Safety

Materials

1. chest tube kit
   1. Introducer needle
   2. Fascial dilators
   3. Chest tube +/- stiffening dilator
2. sterile setup
3. anesthetic (bupivacaine with epinephrine)
4. pleural evacuation device and suction setup

Technique

1. If using ultrasound, mark the best site (largest effusion depth).
2. Clean the site.
3. Anesthetize (see below)
   1. skin
   2. periosteum
   3. deep tissues
   4. pleural space
4. Enter the pleural space with negative pressure on an introducer needle/syringe. Enter just over the top of the rib
5. guidewire insertion
6. Introducer needle out
7. Cut
8. Dilate over guidewire. May have to rotate/pull to break the soft tissues. Aim superiorly for a pneumothorax, and posteriorly for a pleural effusion.
9. Pigtail on guidewire. Then advance the pigtail catheter.
10. Guidewire out. Cover to prevent air entry.
11. Connect to pleur-evac or atrium device.

Secure and Dressing

• Suture
  • mattress or simple interrupted. Avoid purse-string suture.
  • roman sandal wrap
• Vaseline-impregnanted gauze
• Tension bandage over

Surgical Tube Thoracostomy

Chest-Tube Insertion | NEJM Technique for Chest Tube Insertion | CTSNet Surgeon Shows How to Place a CHEST TUBE | Behind the Knife - Bedside Procedures Episode 1 - YouTube 6. Chest Tube Insertion - TNS Trauma Procedure Video Series - YouTube

Location: Complications of Pleural Procedures > Triangle of Safety

Materials

1. 28-32 French chest tube
2. Local anesthetic if awake/conscious
3. Kelly clamps x 2
4. Scalpel and blade (#10, #11)
5. 0 suture and suture kit
6. Drainage setup (Pleur-Evac)

Antibiotics

Antibiotic prophylaxis is conditionally recommended by EAST guidelines in the setting of tube thoracostomies for penetrating chest trauma.

• Tends to reduce empyema; however no clear reduction in pneumonia or mortality.
• Antibiotics tended to be 1st/2nd generation cephalosporins or clindamycin. Regimens highly varied but generally covered with antibiotics until the tube thoracostomy was removed.
• Infections tended to be from skin flora (Staph/Strep)
• Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma | Trauma Surgery & Acute Care Open