8-7
insert an ET tube, or other long airway more than 3-4 inches to avoid intubating a single bronchus.
Inflate the ET cuff if applicable. Do NOT release the airway tube until it is secured (see below).
g. Connect the Ambu bag to the tube and inflate the lungs, or have someone perform mouth to tube
respirations. Auscultate the abdomen and both lung fields while observing for bilateral rise and fall of
the chest. If there are bilateral breath sounds and bilateral rise and fall of the chest, the tube is properly
placed and may be secured (see below). If not, reposition the tube as follows until adequate placement
is obtained: (1) Unilateral breath sounds and unilateral rise or fall of the chest indicate that the tube is
past the carina. Deflate the cuff on an ET tube, retract the tube 1-2 inches, inflate the ET cuff and
recheck air exchange and placement. (2) Air coming out of the casualty’s mouth indicates that the
tube is pointed away from the lungs. Deflate the cuff on an ET tube, remove the tube, reinsert,
inflate the cuff and recheck for air exchange and placement. (3) Any other problem indicates tube is
not in the trachea. Follow the preceding step.
h. If air flows freely, and the patient is breathing on his own, proceed to next step. If the patient is NOT
breathing on his own, continue providing respirations via the Ambu bag with oxygen if available, or via
mouth to tube assistance at the rate of about 20/min.
i. Secure the airway tube using tape (temporary), or use the 3-0 suture to make a stitch through
the skin beside the tube. Secure the tube to the stitch with several knots.
j. Suction the casualty’s airway, as necessary. Insert the suction catheter 4 to 5 inches into the tube.
Apply suction only while withdrawing the catheter. Administer 1 cc of saline solution into the airway to
loosen secretions and help facilitate suctioning. NOTE: Ventilate the casualty several times or allow him
to take several breaths between suctionings.
- Apply a dressing to further protect the tube or catheter and incision using one of the techniques below.
a. Cut two 4 X 4s or 4 X 8s halfway through. Place them on opposite sides of the tube so that the tube
comes up through the cut and the gauze overlaps. Tape securely.
b. Apply a sterile dressing under the casualty’s tube by making a V-shaped fold in a 4 X 8 gauze pad and
placing it under the edge of the catheter to prevent irritation to the casualty. Tape securely. - Monitor casualty’s respirations on a regular basis.
a. Reassess air exchange and placement every time the casualty is moved.
b. Assist respirations if respiratory rate falls below 12 or rises above 20 per minute.
What Not To Do:
Do not remove needle before advancing the catheter into trachea. (NEEDLE Cricothyroidotomy)
Do not forget to insure that the tube is correctly placed, and secured. (SURGICAL Cricothyroidotomy)
Do not fail to monitor.
Procedure: Thoracostomy, Needle and Chest Tube
COL Warren Whitlock, MC, USAWhat: Mechanisms to treat pneumothorax and hemothorax.
When: A needle thoracostomy can be performed faster than a tube thoracostomy in a rapidly deteriorating
patient having signs of a tension pneumothorax. This can be life saving and gives enough relief to provide time
for the medic to insert a chest tube. Once the chest tube is properly inserted, remove the needle.
What You Need: 18 gauge needle, 16-18 gauge Intracath, 10-20 cc syringe, sterile saline, alcohol pads,
Betadine, latex sterile gloves, assorted chest tubes (sizes 28-32 French for adult pending air evacuation,
36-40°F for adult with hemothorax, 12-14°F for children), water seal drainage system (e.g., Pleur-Evac) and
connection tubing for suction (alternate: one-way valve made from nger of latex glove), instruments: scalpel,
forceps, gauze (may be in prepared tray), Lidocaine 1-2 % without epinephrine, petrolatum gauze, external
dressing (4x4), adhesive tape, pulse oximetry
What To Do:
Figure out which lung has the pneumothorax! Insure that the procedure is performed on the side suspected