This self instructional unit is designed for
use with the medical student who has completed
or is taking gross anatomy.
There are a number of ways to perform this procedure.
We are demonstrating only one technique
upon completion of this unit,
you should be able to: One: list and
sequence nine key steps for performing the
closed chest tube.
thoracotomy. Two:
locate either on yourself or another person.
The exact position for the superficial
incision and the exact position for the chest
wall puncture.
Three,
you will be shown a different recording of the same
procedure while observing this second
operation list,
all departures from the recommended procedure
and which of the nine key steps are
omitted.
This is a middle aged male who has suffered a
penetrating wound to the chest.
The X ray demonstrates a significant hemo
pneumothorax which will require a closed
tube thoro to expand the collapsed
lung.
The patient is placed in the right lateral decubitus
position with the left upper extremity
extended over the head.
The tube will be placed in the fifth intercostal
space in the anterior axillary line.
A scar from a previous chest tube can be seen.
The chest is shaved and prepared in a routine
fashion with IO to four solution.
A sterile ice sheet is placed over the site
chosen for the skin incision.
A 25 gauge needle is used to make a
small skin wheel at sight of the
incision.
A large needle is used to anesthetize
the subcutaneous tissue of the whole area.
Then the muscles and the plea of the
fourth intercostal space are
anesthetized
after the anesthetic has taken effect.
A transverse decision is made at the
fifth intercostal space.
This incision,
four centimeters in length is extended through
the subcutaneous tissue down to the muscle.
The fourth intercostal space superior to the
incision is then identified.
A kelly clamp is then used to bluntly
dissect through the muscle layers
and puncture.
The parietal pleura
care must be taken to avoid injury to
the lung when entering the pleural cavity.
In this diagrammatic coronal section
of the left chest,
we can see that by entering the plural space,
one intercostal space higher than the skin
incision.
A subcutaneous tunnel is created which
helps to prevent air leaks around the chest tube.
Also the occlusion of this tunnel when the tube is
removed will prevent the entrance of air
into the plural space.
Using the finger,
we then verify complete penetration of the
parietal pleura and the separation of
the lungs,
visceral and the parietal pleura.
This is a 32 gauge plastic
chest tube which has numerous holes
placed circumferentially around the blunt tip
the blunt end of the tube is gripped by the Kelly
clamp.
And after the previously created
tunnel is located,
the tube is introduced into the plural cavity.
The clamp is withdrawn as soon as the tube is
within the plural space.
The tube is positioned posteriorly
and its tip is directed toward the apex of the
plural cavity.
As seen in this X ray.
A clamp is used to prevent premature drainage of
the blood from the plural cavity and to
prevent additional air from entering
the tube is placed at the medial end of the incision
and interrupted sutures are used to close the
lateral incision.
Then a purse string suture is placed around the
chest tube.
This will be tied only after the chest tube
has been removed,
loose ends of the purse string are
rolled around the suture package and
positioned against the chest wall.
The ice sheet is then removed
of benzoin is applied to enhance
adhesiveness and to prevent skin
irritation.
When the tube is taped to the chest wall.
A gauze sponge with a Y shaped
incision is placed around the base of the
chest tube and
taped in place.
The chest tube is then secured to the chest
wall to prevent accidental
removal.
Taping the tube close will also
help to prevent irritation when the patient
moves.
The tube is then attached to a drainage
system
and each connection is securely taped.
The clamp is removed from the tube
and the trapped blood and air are allowed to
escape from the left plural space
into the two bottle drainage system.
The water sealed trap bottle on the left
collects the blood and air.
The control bottle provides for a regulated
negative suction on the water seal
bottle.
To facilitate plural cavity drainage.
The center tube should be adjusted to between
10 and 20 centimeter column of water.
A self evaluation period follows.
Please respond as requested
on a sheet of paper list.
In sequential order,
the nine key steps for performing the closed
chest tube.
Thom,
your answer should have been one.
Locate the puncture site.
The fifth intercostal space in the
anterior axillary line,
two,
prepare the operation site.
Three,
administer the local anesthetic.
Four,
make superficial incision over the fifth
intercostal space.
Five,
make chess wall dissection through the fourth
intercostal space
six.
Verify complete dissection with the finger
seven,
insert the chest tube,
eight,
secure the chest tube.
Nine connect the chest tube to the
drainage system.
Locate either on yourself another
person or on the TV.
Monitor the exact position for
the incision and the exact position
for the chest wall puncture.
First,
we locate and mark the anterior axillary
line.
Then we palpate the joint between
the manubrium and the body of the sternum.
This indicates the second rib.
The first interspace is just above,
we then count down to the fifth
interspace.
The incision will be made at the fifth
intercostal space in the anterior
axillary line and the chest wall
puncture will be made superior to the
incision in the fourth intercostal space.
You will now see a different recording of a
closed chest tube thot
while observing this operation.
Please list all the departures from the
recommended procedures and which of the nine
key steps have been omitted.
There will be no sound on this portion.
Now,
let's see how well you have done.
First of all,
the patient is not in the right lateral decubitus
position.
And although the physician has determined the incision
site,
he does not compare it with any anatomical
landmark.
Draping of the operation site is not complete
as a sterile ice sheet has not been
used.
The anesthetic is not administered to the
deeper tissues.
Scissors are used for the blunt dissection.
The dissection is not properly verified with the
finger.
Although the space between the ribs can be felt,
the tissues have evidently not been properly
dissected as four attempts to
insert the tube meet with failure.
Finally,
the finger is inserted deep enough to complete the
dissection.
But even now,
the separation of the visceral and the parietal
pleura is not verified.
Vaseline gauze is placed directly over
the wound.
This is not necessary as
suturing has closed the tunnel and the
Vaseline gauze hinders healing and
affords a place for bacteria and germ
growth.
The control bottle of the two bottle drainage
system has not been
connected to a vacuum