WEBVTT

00:00.000 --> 00:30.000 position:50% align:top line:0%
*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

00:07.969 --> 00:10.720
This self instructional unit is designed for

00:10.729 --> 00:13.420
use with the medical student who has completed

00:13.670 --> 00:15.619
or is taking gross anatomy.

00:16.440 --> 00:19.250
There are a number of ways to perform this procedure.

00:19.770 --> 00:22.129
We are demonstrating only one technique

00:22.930 --> 00:24.879
upon completion of this unit,

00:25.299 --> 00:28.229
you should be able to: One: list and

00:28.239 --> 00:31.209
sequence nine key steps for performing the

00:31.219 --> 00:32.770
closed chest tube

00:32.779 --> 00:35.549
thoracotomy. Two: 

00:35.630 --> 00:38.430
locate either on yourself or another person.

00:38.650 --> 00:40.919
The exact position for the superficial

00:40.930 --> 00:43.900
incision and the exact position for the chest

00:43.909 --> 00:44.750
wall puncture.

00:47.090 --> 00:47.740
Three,

00:47.900 --> 00:50.290
you will be shown a different recording of the same

00:50.299 --> 00:52.880
procedure while observing this second

00:52.889 --> 00:54.349
operation list,

00:54.360 --> 00:57.139
all departures from the recommended procedure

00:57.490 --> 01:00.020
and which of the nine key steps are

01:00.029 --> 01:00.540
omitted.

01:03.450 --> 01:05.860
This is a middle aged male who has suffered a

01:05.870 --> 01:07.739
penetrating wound to the chest.

01:08.419 --> 01:11.080
The X ray demonstrates a significant hemo

01:11.489 --> 01:14.269
pneumothorax which will require a closed

01:14.279 --> 01:16.970
tube thoro to expand the collapsed

01:16.980 --> 01:17.589
lung.

01:17.830 --> 01:20.620
The patient is placed in the right lateral decubitus

01:20.629 --> 01:23.540
position with the left upper extremity

01:23.550 --> 01:24.819
extended over the head.

01:25.650 --> 01:28.300
The tube will be placed in the fifth intercostal

01:28.309 --> 01:30.900
space in the anterior axillary line.

01:32.239 --> 01:35.160
A scar from a previous chest tube can be seen.

01:36.779 --> 01:39.629
The chest is shaved and prepared in a routine

01:39.639 --> 01:41.750
fashion with IO to four solution.

01:46.279 --> 01:48.750
A sterile ice sheet is placed over the site

01:48.760 --> 01:50.629
chosen for the skin incision.

01:56.860 --> 01:59.349
A 25 gauge needle is used to make a

01:59.360 --> 02:01.940
small skin wheel at sight of the

02:01.949 --> 02:02.589
incision.

02:15.419 --> 02:18.339
A large needle is used to anesthetize

02:18.350 --> 02:20.830
the subcutaneous tissue of the whole area.

02:35.639 --> 02:38.550
Then the muscles and the plea of the

02:38.559 --> 02:40.669
fourth intercostal space are

02:40.679 --> 02:41.669
anesthetized

02:53.399 --> 02:55.809
after the anesthetic has taken effect.

02:55.949 --> 02:58.910
A transverse decision is made at the

02:58.919 --> 03:00.570
fifth intercostal space.

03:05.779 --> 03:06.789
This incision,

03:06.800 --> 03:09.710
four centimeters in length is extended through

03:09.720 --> 03:12.309
the subcutaneous tissue down to the muscle.

03:21.490 --> 03:24.169
The fourth intercostal space superior to the

03:24.179 --> 03:26.220
incision is then identified.

03:38.800 --> 03:41.309
A kelly clamp is then used to bluntly

03:41.320 --> 03:43.830
dissect through the muscle layers

03:44.130 --> 03:44.940
and puncture.

03:44.949 --> 03:46.009
The parietal pleura

03:49.610 --> 03:52.610
care must be taken to avoid injury to

03:52.619 --> 03:55.119
the lung when entering the pleural cavity.

03:57.419 --> 04:00.149
In this diagrammatic coronal section

04:00.250 --> 04:01.720
of the left chest,

04:01.990 --> 04:04.419
we can see that by entering the plural space,

04:04.429 --> 04:06.949
one intercostal space higher than the skin

04:06.960 --> 04:07.789
incision.

04:08.110 --> 04:10.860
A subcutaneous tunnel is created which

04:10.869 --> 04:13.630
helps to prevent air leaks around the chest tube.

04:14.199 --> 04:16.820
Also the occlusion of this tunnel when the tube is

04:16.829 --> 04:19.660
removed will prevent the entrance of air

04:19.670 --> 04:21.049
into the plural space.

04:23.890 --> 04:25.220
Using the finger,

04:25.380 --> 04:28.000
we then verify complete penetration of the

04:28.010 --> 04:30.980
parietal pleura and the separation of

04:30.989 --> 04:31.480
the lungs,

04:31.489 --> 04:34.459
visceral and the parietal pleura.

04:40.890 --> 04:43.760
This is a 32 gauge plastic

04:43.769 --> 04:46.670
chest tube which has numerous holes

04:46.679 --> 04:49.260
placed circumferentially around the blunt tip

04:55.279 --> 04:58.170
the blunt end of the tube is gripped by the Kelly

04:58.179 --> 04:58.730
clamp.

05:03.640 --> 05:06.470
And after the previously created

05:06.480 --> 05:07.890
tunnel is located,

05:09.709 --> 05:12.679
the tube is introduced into the plural cavity.

05:14.100 --> 05:16.859
The clamp is withdrawn as soon as the tube is

05:16.869 --> 05:18.269
within the plural space.

05:19.290 --> 05:21.500
The tube is positioned posteriorly

05:22.690 --> 05:25.429
and its tip is directed toward the apex of the

05:25.440 --> 05:26.260
plural cavity.

05:26.269 --> 05:27.809
As seen in this X ray.

05:28.609 --> 05:31.579
A clamp is used to prevent premature drainage of

05:31.589 --> 05:34.149
the blood from the plural cavity and to

05:34.160 --> 05:36.320
prevent additional air from entering

05:38.739 --> 05:41.670
the tube is placed at the medial end of the incision

05:41.950 --> 05:44.540
and interrupted sutures are used to close the

05:44.549 --> 05:45.670
lateral incision.

05:58.369 --> 06:01.260
Then a purse string suture is placed around the

06:01.269 --> 06:01.940
chest tube.

06:02.679 --> 06:05.540
This will be tied only after the chest tube

06:05.549 --> 06:06.609
has been removed,

06:13.410 --> 06:16.100
loose ends of the purse string are

06:16.109 --> 06:18.970
rolled around the suture package and

06:18.980 --> 06:21.329
positioned against the chest wall.

06:27.540 --> 06:29.869
The ice sheet is then removed

06:54.570 --> 06:57.040
of benzoin is applied to enhance

06:57.049 --> 06:59.769
adhesiveness and to prevent skin

06:59.779 --> 07:00.549
irritation.

07:00.559 --> 07:02.760
When the tube is taped to the chest wall.

07:07.500 --> 07:09.790
A gauze sponge with a Y shaped

07:09.799 --> 07:12.549
incision is placed around the base of the

07:12.559 --> 07:15.440
chest tube and

07:15.450 --> 07:16.660
taped in place.

07:39.790 --> 07:42.540
The chest tube is then secured to the chest

07:42.549 --> 07:44.899
wall to prevent accidental

07:44.910 --> 07:45.589
removal.

08:10.640 --> 08:13.640
Taping the tube close will also

08:13.649 --> 08:16.040
help to prevent irritation when the patient

08:16.049 --> 08:16.730
moves.

08:20.799 --> 08:23.589
The tube is then attached to a drainage

08:23.600 --> 08:24.130
system

08:29.410 --> 08:31.940
and each connection is securely taped.

08:35.409 --> 08:37.500
The clamp is removed from the tube

08:42.210 --> 08:45.140
and the trapped blood and air are allowed to

08:45.150 --> 08:47.580
escape from the left plural space

08:47.859 --> 08:50.460
into the two bottle drainage system.

08:58.080 --> 09:00.690
The water sealed trap bottle on the left

09:00.859 --> 09:02.570
collects the blood and air.

09:03.719 --> 09:06.559
The control bottle provides for a regulated

09:06.570 --> 09:09.059
negative suction on the water seal

09:09.070 --> 09:09.690
bottle.

09:09.979 --> 09:12.690
To facilitate plural cavity drainage.

09:13.419 --> 09:16.030
The center tube should be adjusted to between

09:16.039 --> 09:18.789
10 and 20 centimeter column of water.

09:25.239 --> 09:27.880
A self evaluation period follows.

09:28.020 --> 09:30.349
Please respond as requested

09:33.979 --> 09:36.570
on a sheet of paper list.

09:36.580 --> 09:37.719
In sequential order,

09:37.729 --> 09:40.710
the nine key steps for performing the closed

09:40.719 --> 09:41.869
chest tube.

09:42.349 --> 09:42.530
Thom,

11:05.119 --> 11:07.590
your answer should have been one.

11:07.599 --> 11:09.330
Locate the puncture site.

11:09.599 --> 11:11.859
The fifth intercostal space in the

11:11.869 --> 11:13.770
anterior axillary line,

11:17.450 --> 11:18.090
two,

11:18.200 --> 11:20.289
prepare the operation site.

11:32.460 --> 11:33.320
Three,

11:33.419 --> 11:35.599
administer the local anesthetic.

11:42.630 --> 11:43.130
Four,

11:43.140 --> 11:45.780
make superficial incision over the fifth

11:45.789 --> 11:47.119
intercostal space.

11:53.440 --> 11:54.080
Five,

11:54.090 --> 11:57.049
make chess wall dissection through the fourth

11:57.059 --> 11:58.409
intercostal space

12:03.179 --> 12:03.979
six.

12:04.119 --> 12:06.989
Verify complete dissection with the finger

12:13.630 --> 12:14.419
seven,

12:14.429 --> 12:15.989
insert the chest tube,

12:28.349 --> 12:29.010
eight,

12:29.130 --> 12:30.919
secure the chest tube.

12:43.539 --> 12:46.309
Nine connect the chest tube to the

12:46.320 --> 12:47.390
drainage system.

12:59.020 --> 13:01.849
Locate either on yourself another

13:01.859 --> 13:03.750
person or on the TV.

13:03.760 --> 13:06.719
Monitor the exact position for

13:06.729 --> 13:09.690
the incision and the exact position

13:09.700 --> 13:11.309
for the chest wall puncture.

13:45.549 --> 13:46.099
First,

13:46.109 --> 13:49.010
we locate and mark the anterior axillary

13:49.020 --> 13:49.440
line.

13:53.059 --> 13:55.919
Then we palpate the joint between

13:56.090 --> 13:58.609
the manubrium and the body of the sternum.

13:58.989 --> 14:01.070
This indicates the second rib.

14:02.400 --> 14:04.679
The first interspace is just above,

14:05.869 --> 14:08.109
we then count down to the fifth

14:08.119 --> 14:09.039
interspace.

14:15.070 --> 14:17.780
The incision will be made at the fifth

14:17.789 --> 14:20.169
intercostal space in the anterior

14:20.179 --> 14:23.010
axillary line and the chest wall

14:23.020 --> 14:25.469
puncture will be made superior to the

14:25.479 --> 14:28.179
incision in the fourth intercostal space.

14:30.719 --> 14:33.440
You will now see a different recording of a

14:33.450 --> 14:34.900
closed chest tube thot

14:36.229 --> 14:38.330
while observing this operation.

14:38.710 --> 14:41.479
Please list all the departures from the

14:41.489 --> 14:44.429
recommended procedures and which of the nine

14:44.440 --> 14:46.380
key steps have been omitted.

14:47.359 --> 14:49.729
There will be no sound on this portion.

19:22.579 --> 19:22.910
Now,

19:22.920 --> 19:24.750
let's see how well you have done.

19:25.770 --> 19:26.859
First of all,

19:27.030 --> 19:29.969
the patient is not in the right lateral decubitus

19:29.979 --> 19:30.599
position.

19:31.949 --> 19:34.699
And although the physician has determined the incision

19:34.709 --> 19:35.339
site,

19:35.630 --> 19:38.329
he does not compare it with any anatomical

19:38.339 --> 19:39.040
landmark.

19:40.099 --> 19:43.060
Draping of the operation site is not complete

19:43.319 --> 19:45.699
as a sterile ice sheet has not been

19:45.709 --> 19:46.349
used.

19:53.969 --> 19:56.810
The anesthetic is not administered to the

19:56.819 --> 19:57.939
deeper tissues.

20:18.739 --> 20:21.550
Scissors are used for the blunt dissection.

20:24.680 --> 20:27.469
The dissection is not properly verified with the

20:27.479 --> 20:27.930
finger.

21:06.880 --> 21:09.689
Although the space between the ribs can be felt,

21:10.010 --> 21:12.410
the tissues have evidently not been properly

21:12.420 --> 21:15.050
dissected as four attempts to

21:15.060 --> 21:17.689
insert the tube meet with failure.

21:33.479 --> 21:34.569
Finally,

21:34.689 --> 21:37.369
the finger is inserted deep enough to complete the

21:37.380 --> 21:38.130
dissection.

21:38.689 --> 21:39.569
But even now,

21:39.579 --> 21:42.219
the separation of the visceral and the parietal

21:42.229 --> 21:44.449
pleura is not verified.

22:45.329 --> 22:48.290
Vaseline gauze is placed directly over

22:48.300 --> 22:49.000
the wound.

22:49.839 --> 22:52.410
This is not necessary as

22:52.420 --> 22:55.239
suturing has closed the tunnel and the

22:55.329 --> 22:57.890
Vaseline gauze hinders healing and

22:57.900 --> 23:00.739
affords a place for bacteria and germ

23:00.750 --> 23:01.359
growth.

23:18.869 --> 23:21.819
The control bottle of the two bottle drainage

23:21.829 --> 23:24.530
system has not been

23:24.540 --> 23:25.920
connected to a vacuum