Procedural Competency Form: Simulation/Cadaver Lab
Tube Thoracostomy
Resident:_______________________________________
Date:__________________
Observing faculty:________________________________
Knowledge Assessment
1. Indications?
2. Important contraindications?
3. Necessary equipment?
4. Complications?
5. Describe how you would obtain informed consent in the stable patient.
Checklist of performance:
Pre-procedure
Demonstrates ability to obtain informed consent when appropriate
Evaluates patient/anatomy for potential difficulty
Applies oxygen, monitor
Prepares and checks equipment
Positions patient correctly (arm over head to open up ribs)
Verbalizes use of sedation and analgesia
Procedure
Observes universal precautions (gown, mask, cap, gloves, drapes)
Administers local anesthetic (2% Lido to skin, rib, muscles, down to pleura)
Incises the skin (3-4cm incision) at 4th or 5th IC space, mid-axillary line
Insert Kelly clamp and spread tissues down to pleura
“Pop” through pleura with appropriate pressure and spread the clamp
Insert finger to palpate pleura and lung
Use Kelly clamp to insert tube and position appropriately (clamped end)
Post-procedure
Secures tube with silk suture
Applies appropriate dressing (vasoline gauze, cut 4x4’s,and tape)
Orders and reviews post intubation chest x-ray
Describes documentation (consent, indication, procedure, complications)
Assessment (circle one):
Unsatisfactory
Area for improvement
Yes
No
N/A
Satisfactory
Comments:
Faculty signature:_____________________________________________________________
Resident signature:____________________________________________________________
Tube Thoracostomy Notes
Indications
 Pneumothorax
o Spontaneous
o Open
o Tension
 Hemothorax
 Empyema
 Severe effusions
 Flail chest requiring mechanical ventilation
 Prophylaxis before transport to a trauma center
Contraindications
 For unstable injured patients with a pneumothorax or hemothorax, there are no absolute
contraindications.
 In the stable patient, relative contraindications include coagulopathy, adhesions, or
emphysematous blebs.
Equipment
 Sterile drapes and towels
 Antiseptic solution (Betadine)
 20mL syringe with 18 and 25 gauge needles for anesthetic
 20mL of 2% Lidocaine +/- epinephrine
 No. 10 scalpel
 Large Kelly clamps x2
 Chest tubes 28-36F
 Needle driver
 Forceps
 Large, straight and curved scissors
 0 or 1-0 silk on large cutting needles
 Gauze pads
 Adhesive tape—cloth backed
 Drainage set-up (Pleuravac kit)
o Clear, sterile plastic tubing in 6-foot lengths, ½-inch diameter
o Hard plastic serrated connectors
o Drainage apparatus with sterile water for water seal
o Y connectors
o Drainage and suction systems
Complications
 Misplaced tube (along chest wall, subQ, or intra-abdominal/liver/sleen)
 Infection
 Laceration of an intercostal vessel or lung parenchyma
 Subcutaneous air leak
 Bleeding
Indications for Surgery After Tube Thoracostomy
 Massive hemothorax, >1000–1500 mL initial drainage
 Continued bleeding
o 300–500 mL in first hour
o 200 mL/hour for first 3 or more hours
 Increasing size of hemothorax on chest film
 Persistent hemothorax after 2 functioning tubes placed
 Clotted hemothorax
 Large air leak preventing effective ventilation
 Persistent air leak after placement of second tube or inability to expand lung fully