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Breathing - Thoracostomy (open)

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Indications

Traumatic cardiac arrest (bilateral starting on injured side)

Failed needle thoracostomy in tension pneumothorax

Contraindications (absolute in bold)

Spontaneous ventilation

Alternatives

Needle thoracostomy

Small intercostal catheter (Seldinger technique)

Large intercostal catheter (blunt dissection size 24-32Fr)

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Failure to decompress

Pain

Haemorrhage

Neurovascular, visceral and pulmonary parenchymal damage

Occlusion with recurrence of tension pneumothorax (requiring re fingering)

Infection

Procedural hygiene

Standard precautions

Surgical aseptic non-touch technique

PPE: double sterile gloves (if performing finger sweep), sterile surgical gown, surgical mask, eye protection

Area

Resuscitation bay

Staff

Procedural clinician and assistant

Equipment

Scalpel

Clamp (Howard Kelly or equivalent)

Positioning

On the bed with head elevated to 45 degrees

Arm on the side of the lesion behind the patient’s head (abducted and externally rotated)

or

Supine with arm out to the side on side of lesion (crucifix position)

Locate safe triangle: lateral to pectoralis major, medial to latissimus dorsi, fourth or fifth intercostal space, anterior to mid-axillary line

With the arm by the side, mark the anterior mid-arm point from shoulder tip to antecubital fossa (preferred), or

Place your open hand in the axilla and mark the edge of the hand between the anterior and mid-axillary line, or

Palpate the second intercostal space at the sternal angle, move down two spaces and palpate space around to the axilla

It is common for incisions to be too low in the chest, with risk of visceral injury

Place an intercostal space higher in pregnant patients due to increased elevated diaphragm

Medication

20ml lignocaine 1% with adrenaline (1:100,000)

Cephazolin IV 2g

Consider:

Ketamine IV 10-20mg (pain relief pre-procedure adjusted to co-morbid status)

Morphine IV 5-10mg (opioid pain relief pre-procedure adjusted to co-morbid status)

Midazolam IV 1-2mg (anxiolytic pre-procedure adjusted to co-morbid status)

Sequence

Anaesthetise skin, soft tissue, muscle and periosteum (unless arrested or peri-arrest)

Incise 4cm just above and parallel with the upper border of rib at insertion site (avoiding neurovascular bundle)

Hold clamp with only 4cm exposed distal to fingers to reduce chance of lung injury

Push clamp slightly upwards through muscle to enter the pleural space with likely ‘give’ and ‘gush’ of air or blood

Open clamp slightly with likely further ‘gush’ of air or blood, then close

Rub clamp side to side on superior margin of rib below to bluntly dissect a hold large enough for a chest drain

Palpate through thoracotomy with little finger, opening tract and confirming position in thoracic cavity (optional)

Perform a finger sweep of pleura around thoracostomy excluding pleural adhesions (optional)

Post-procedure care

Immediate large intercostal catheter (unless intubated, ventilated and heading directly to theatre)

Provide analgesia

Antibiotics (2g cefazolin)

Document procedure (completion, technique and any immediate complications)

Tips

Palpate rib borders prior to incision, orienting yourself to the anatomy (ribs angle inferiorly as you move anterior)

Locating landmarks by mid-arm point is evidence-based and our recommended method

Skin markings made at the mid-arm point move slightly superior with abduction, still incise at the marking

Immediate catheter placement is indicated after thoracostomy in a spontaneously breathing patient

Antibiotics and good aseptic technique reduce the significant risk of infection (empyema and pneumonia)

Discussion

The triangle of safety is the key landmark. A significant proportion of chest drains and thoracostomies are placed outside of this area due to procedural error. Of the various methods for determining correct position of placement, rapid measurement of mid-arm point appears the most practical and accurate and is our preferred method.

Making an oblique track slightly upwards (<45 degrees) and through the intercostal space reduces the risk of chest tube placement in the lung fissure, which is associated with increased failure requiring replacement. We advocate entering the rib space low to enable an oblique path to be formed.

The finger sweep is a useful part of chest tube placement, confirming position in the thoracic cavity, maintaining the track and excluding lung and pleural adhesions (which increase the risk of parenchymal injury and fissure placement). The finger sweep carries a risk of sharps injury to the proceduralist if broken ribs are present. We advocate a cautious finger sweep using double gloves for increased sharps protection. Easily disrupted adhesion should be lysed with the finger. Firm adhesions require an alternative site of tube placement. The finger sweep should be omitted in trauma patients suspected to be at high risk of blood-borne pathogens (hepatitis B, C or HIV). The proceduralist is required to make this judgement at the bedside and is it acceptable for providers to choose to always omit a finger sweep in trauma due to risk of sharps injury.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 11.10 – resuscitation in special circumstances. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2010. 14pp. Available from https://resus.org.au/guidelines/

Ambulance Service of NSW. Blunt thoracic trauma. Report HELI.CLI.09. Sydney: ASNSW; 2013. 5pp. Available from: https://sydneyhems.com/resources/policies-and-procedures/

NSW Agency for Clinical Innovation. Consensus guideline: pleural drains in adults. Sydney: ACI; 2016. 55pp. Available from: https://www.aci.health.nsw.gov.au/resources/respiratory/pleural-drains/pleural-drains-in-adults

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