Thoracostomy blunt dissection technique

 

Indications

 

• Pneumothorax

Consider using a smaller catheter inserted via seldinger technique for 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

Tip – use a towel or sheet to secure arm in place for procedure

 

 

2. Mark site of insertion

4^th or 5^th intercostal space in the anterior axillary line

The “triangle of safety”

Anteriorly: lateral border of pectoralis major

Posteriorly: anterior border of latissimus dorsi

Inferiorly: 5^th intercostal space

 

Tip – this equates to around the nipple line in male

Tip – If in doubt, go a space higher

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

 

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

 

 

3. Don PPE

Gown, gloves, mask, eye protection

 

4. Aseptic technique

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

 

Clean area with antiseptic solution

Place drapes

 

5. 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. This is indicated to ensure depth of placement of local anaesthetic.

May aspirate blood with a haemothorax (depending on coagulation)

 

6. Incise skin

Make a transverse 2-3cm skin incision directly over the inferior rib (ie: 5^th or 6^th rib)

The aim is then to proceed above and over this rib

 

7. Blunt dissect

Through intercostal muscles using curved forceps

Aim to go OVER the rib to avoid the neurovascular bundle

The technique involves pushing in a little then opening the forceps and repeating. Three or four insertions and spreadings are required. Don’t try and push it all the way before opening.

Pierce the pleura

Signalled by a rush of blood in haemothorax or whoosh of air in pneumothorax

 

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

Tip – Create a hole large enough for drain placement as evident by being a able to insert an index finger.

 

8. Place finger inside pleural cavity and “sweep”

Ensure you are inside the correct space and not abutting diaphragm or intraperitoneal contents

 

Tip – 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.

 

9. Place chest drain

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

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

Tip – Do not push it straight in. It will go into the fissure between the lobes and not drain effectively.

Tip – aim drain cephalad for a pneumothorax and caudal for a haemothorax

Tip – don’t use a trocar, this can cause serious injury to underlying structure

 

 

10. 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

 

Tip – place brown tape over all drain connections to prevent accidental detachment

 

11. Suture drain to skin and place dressings

 

12. CXR

Confirm correct position

 

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

https://youtu.be/IdmMR8JxmFo

 

 

 

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, or in the fissure between the lobes of the lung
  • 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