EMERGENCY DEPARTMENT · WALL POSTER

Chest Tube

DECIDEDrain air or fluid from the pleural cavity — pneumothorax, hemothorax, effusion/empyema. · Pleural lavage — active internal rewarming in severe hypothermia.

STEPS · ◆ KEY STEP — LOGGED WITH ITS TIME

PREP — MD AND RN IN PARALLEL

Open your kit onto the sterile field.
Gown and gloves.
Select the tube size — 28–32 Fr for blood, 24–28 Fr for air, 14 Fr pigtail. Sizes live loose on the shelf.
Prep the skin — ChloraPrep.
Drape. Fenestrated + regular ½ drape — both are in the kit.
Draw up lidocaine 1%, 20 mL, with the 21 g and 25 g needles.
Antibiotic prophylaxis.
Prime the Pleur-evac (underwater-seal drain) and bring it to the bedside.
Monitor and analgesia — continuous pulse oximetry and cardiac monitor; analgesia or sedation per order.
Have ready: large Tegaderm from the kit, and the separate dressing kit.

TECHNIQUE — STEP BY STEP

BOTHPosition: supine or head up 30–45°, arm on the affected side abducted or behind the head.
MDLandmark the safe triangle: 4th–5th intercostal space, anterior-to-mid axillary line — anterior border of latissimus dorsi, lateral border of pectoralis major, above the 5th ICS (nipple line). Palpate and confirm before prepping.
MDIncise 2–4 cm through skin, parallel to and directly over the rib below the target space.
MDBlunt-dissect with the Kelly over the top of that rib — the neurovascular bundle runs under each rib's inferior edge.
MDPunch through the parietal pleura with the closed clamp — expect a loss of resistance and a hiss of air or rush of blood — then spread to widen the track.
MDFinger sweep: insert a full gloved finger, sweep 360° to confirm you are intrapleural and clear adherent lung. In arrest this is the whole procedure › ◆ FINGER THORACOSTOMY DONE
MDTube: clamp the distal end; guide the tip through the track on curved forceps or your finger — apically for air, posterobasally for blood. Every fenestration must sit inside the pleura.
BOTHConnect to the primed UWSD; confirm fogging, respiratory swing, drainage or bubbling.
BOTHSecure: heavy suture (anchor stitch, wrap and tie to the tube), occlusive dressing; keep the drain ≥45 cm below the chest. CXR to confirm; document the depth marking at skin.
RNDocument time of incision, tube size, depth at skin, and initial drainage volume. Obtain the confirmatory CXR.
RNWatch the output and call the numbers out loud — >1500 mL immediately, or >200 mL/hr — consider thoracotomy.
BOTHMassive hemothorax on insertion → activate the Massive Transfusion Protocol and prepare for possible transfer/operative management. ◆ MTP ACTIVATED

EQUIPMENT

Chest tube: 28–32 Fr for trauma/hemothorax; 24–28 Fr — or a 14 Fr pigtail — for simple pneumothorax.
Underwater-seal drain (UWSD) — the RN primes it in parallel with MD prep.
Scalpel (No. 10 or 11 blade) + two Kelly clamps / curved artery forceps.
Sterile field: ChloraPrep, drapes, gown/gloves/mask.
Lidocaine 1%, 10–20 mL, syringe + needle — if the patient is awake.
To secure: heavy suture (0 or 2-0) + needle driver, gauze, occlusive dressing, tape.

IN THE KIT — 13 ITEMS · ROOM 7 (RESUS BAY) CABINET · CHEST DRAINAGE

ChloraPrep 10.5 mL swab ×1
Povidone-iodine swab — the alternative prep; both are in the bag ×1
Silk 0 sutures ×2
Scalpel No. 10 ×1
Blunt needle — to draw; lidocaine comes from the Omnicell, not the bag ×1
10 mL syringe ×1
25 gauge 1½ needle — to inject ×1
Long curved blunt scissors ×1
Large needle driver ×1
Large Kelly clamp — to dissect ×1
Medium Kelly clamp — on the tube ×1
Fenestrated drape ×1
Half drape ×1

NURSING DRESSING KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · CHEST DRAINAGE

A second bag in the same section. The provider takes the insertion kit; the nurse takes this one.
Large Op-Site 6x8 ×2
4x4 drain sponge ×2
2x2 gauze ×2
Xeroform (or petroleum) dressing 5x9 ×2
Safety pin ×2
3 inch tape ×1 roll
Chest tube clamp ×2
Chest tube troubleshooting resource ×1

ALSO NEEDED — NOT IN THE KIT

Chest tube 28–32 Fr and 24–28 Fr, 14 Fr pigtail, and the primed underwater-seal drain — all stocked loose on the Chest Drainage shelf, not inside the bag. Gown, gloves, mask and eye protection — Trauma Cart · Drawer 5 · PPE. The nursing Chest Tube Dressing Kit is a separate bag: Op-Site, drain sponges, gauze, Xeroform, safety pins, tape, chest tube clamps and the troubleshooting sheet.

FIGURE

Go in over the top of the rib, inside the triangle — never below the nipple line without imaging.

SITE 4–5TH ICS · ANT–MID AXILLARY · INCISION 2–4 CM

TUBE 28–32 FR HEMOTHORAX · 24–28 FR (14 FR PIGTAIL) PTX

UWSD PRIMED · KEPT ≥45 CM BELOW THE CHEST

>1500 ML OUT, OR >200 ML/HR × 2–4 H → THORACOTOMY CALL

PITFALLS & PEARLS

Below the 5th ICS without imaging → liver/spleen/diaphragm injury.

Dissecting under the rib → intercostal vessel hemorrhage.

Recurrent tension: re-examine and re-finger the track.

Prefer finger thoracostomy once they are on positive pressure or arrested.