Tube Thoracostomy: Supplement to NEJM Video

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Tube ThoracostomySupplement to NEJM Video
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Credentialing Process at SBUH

• Watch the video and the 2 supplements
• 20-30 min total
• Post test
• 80 to pass
• Demonstrate skill in Simulation Center
• Drape/prep station
• Insertion station (s)
• Removal station
• Post Insertion Documentation and CXR Review
• Complete supervised procedures

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Supervised Procedures

• Purpose of supervision is education, validation
  of performance and patient safety.
• Your first CT insertion should not be done in an
  emergency situation
• Submit credentials to your residency program
  coordinator. They will update computerized
  credentials.

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Tube Thoracostomy

• 300 CT placed at SBUH per year
• Complications have included improperly placed
  and improperly positioned tubes, solid organ
  injury, skin infection, empyema, recurrent PTX,
  and failure to drain hemothorax
• This program is intended to
• standardize the insertion of Chest Tubes
• reduce complications

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Pre Insertion

• Communication
• Discuss with Attending the contemplated procedure
  and technique
• Inform the nursing staff
• If you are not credentialed, the nurse will stop
  you
• Consent
• Required for all procedures
• Emergency Consent is for true emergencies only,
  and must be documented as such
• Equipment
• ED Trauma Combo Tray or Tube Thoracostomy Tray
• Chest tube of appropriate size
• Suture, blade, LidocaineTM, , syringes and
  needles, Vaseline gauze, 2 inch tape, gauze,
  sterile gown/ gloves/ drapes
• PleurevacTM (will need H2O to fill chambers)
• Suction

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Example of Informed Consent For Chest tube
placement
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Tube Selection

• Disease process determines tube size
• Chest tubes
• 28F or larger to drain blood
• In children, tube should be diameter of little
  finger
• Pigtail Catheters
• Patient comfort
• Used for large pneumothorax, or simple effusions
• Contraindicated in Trauma
• Contraindicated for hemothorax
• When a loculated collection is suspected consider
  pigtail placement under ultrasound or CT
  guidance.

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Pigtail Catheters for Pleural Drainage
Small catheter pigtail shape Comprehensive
Insertion Kit Seldinger Insertion
Techniquemust be credentialed in CVC
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Gauze
Suture
Needle /syringe and local anesthetic agent
Skin Prep
Kelly Clamp
Scissors
Scalpel
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Insertion of CT

• It may be necessary to move breast tissue from
  the site of insertion to avoid injury to the
  tissue. Use the infra mammary crease or fold as
  a guide for insertion.
• Thin patients (children) need careful tunneling
  of the tube in the subcutaneous tissue (to reduce
  risk of recurrence after removal).

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Insertion of Pigtail or Chest Tube

• Universal Protocol (Time Out) to confirm patient,
  procedure site and side
• Hand washing
• Sterile technique is required
• Hat, mask, sterile gown, gloves and drapes
• Unless the patient is in extremis
• Local anesthesia
• Unless the patient is in extremis
• Always through a new skin incision
• Secure with suture
• Do not tape over nipple

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Pigtail Catheters

• ArrowTM Kit
• Advance needle cephalad
  over the top of the rib
  at a 60 degrees angle
• Stop advancing the needle when the pleural space
  is identified by the aspiration of air or fluid
  into the syringe
• Insert the guide wire into the pleural space
  through the needle

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
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• The needle is removed while stabilizing the guide
  wire
• A small incision is made in the skin
• Pass the dilator over the guide wire
• Remove the dilator

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
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• Thread the catheter over the guide wire
• Remove the guide wire
• Secure the catheter to the skin

CLINICAL PROCEDURES IN EMERGENCY MEDICINE 2004
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Post Insertion of Chest Tube or Pigtail

• Assessment
• Tape connection to drainage system and ensure
  functioning
• Place patient on supplemental O2
• Assess patient by auscultating lung fields
• Documentation
• Procedure Note or Trauma Critical Care Preprinted
  Note must be completed
• Order and interpret post insertion CXR
• Document review of CXR in the chart
• Complete credentialing card

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Obtain a Post Insertion CXR
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Post Insertion Paperwork

• Procedure Note Must be Written
• Indication for CT, Size of tube placed, location
• Technique (time out, sterile technique, wide
  local anesthesia, etc)
• Any complications
• Interpretation of post insertion radiographs

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This is NOT an adequate procedure note
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Incorrect and improper note Bilateral chest
tubes were placed, Not bilateral thoracotomies
done
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Incomplete post procedure note No tube
size No location No indication of
complications No equipment reconciliation
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Removal

• Patient verification, site verification
• Hand washing
• Preparation
• Administer O2
• Connect drainage system to suction
• ChuxTM under/around tube
• Prepare occlusive dressing taped on 3 sides
• Patient instruction/education
• Three deep breaths and hold
• Removal
• Pull at inspiration
• Pull fast, pull completely, simultaneously
  placing dressing
• Helpful to have an assistant
• Post removal CXR
• Order it, review it, document the results in the
  chart

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Simulation suggestions

• Some things are hard to simulate
• Over talk. Say out loud everything that you
  would do in a real situation.
• Assume nothing

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Once again, the process

• Watch the video and the supplements
• You are done with this now!
• Post test
• On-line
• In Simulation Center
• Drape/prep station
• Insertion stations
• Pigtail insertion
• Removal
• CXR interpretation
• Complete 2 supervised procedures

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