CHEST INJURIES - Medicine for Mountaineering and Other Wilderness Activities - page 119

The chest tube should be introduced on the top of the rib rather than the undersurface to
avoid the artery there.
Figure 9-4. Site of chest tube insertion
4. Thepositionselectedfortubeinsertiononthechestwallshouldbeinfiltratedwithagen-
erous amount of a local anesthetic such as 15 ml or more of lidocaine.
5a.If the apparatus includes a trochar (a metal inner guide), an approximate 0.25-inch in-
cision should be made on the top border of the rib with a sterile scalpel. The trochar
should be advanced slowly along the upper edge of the rib until resistance is no longer
felt,indicatingentranceintothechestcavity.Thedepthrequiredfortubeplacementvar-
ies with the thickness of the individual's fat and muscle, but for most the tube should
be in the chest cavity within 3 inches. The trochar should be removed, and the tube ad-
vanced further into the chest an additional 2 inches. When the tube is appropriately po-
sitioned in the chest for a tension pneumothorax, an audible rush of air from the tube is
oftenheard.Thechesttubeshouldbeconnectedtothefluttervalve,andthevalveshould
be checked to ensure it is attached in the correct direction.
5b.To insert a chest tube without a trochar, the chest tube should be connected to the flutter
valve first. Inserting a chest tube without a trochar requires a considerably larger skin
opening,usually1.5incheshorizontallyonthetopedgeoftherib.Thescalpel,orprefer-
ably sterile scissors, used to make the skin incision should be used to cut through the fat
and muscle of the chest wall to enter the chest cavity. A sterile finger should be inserted
to confirm entry into the chest cavity, and then the tube should be advanced through this
track. Insertion approximately 5 inches into the chest should be sufficient for the aver-
age individual. If a tension pneumothorax is present, a rush of air occurs. When a clear
plastic tube is used, breathing should result in fogging of the tube.
6. Once the chest tube is in the correct position, it should be anchored to the chest wall to
prevent it from being pulled out of the chest or forced inward too far.
7. Frequently a small amount of blood is expelled through the chest tube. If a consistent
stream of blood exits, a collection bottle should be added to the system ( Fig. 9-5 ) .
Successful insertion of a chest tube to relieve a tension pneumothorax should result in
prompt improvement in the injured individual. However, following rapid reexpansion of
the lung, the individual may experience transient pain with breathing.
Hemothorax