8-8
of having a pneumothorax (tension pneumothorax, simple pneumothorax, hemothorax), which will be the lung
without breath sounds. Hyper-resonance is also a helpful sign, but the lack of breath sounds after penetrating
or blunt trauma is a definitive sign.
Needle Thoracostomy:
- Prep the chest wall by pouring Betadine over the intended site or swab with an alcohol wipe.
- Insert an 18 Ga (or larger) 1.5 inch needle or IV catheter into the 2nd intercostal space, along the
midclavicular line (an imaginary line from the middle of the collarbone, or clavicle; the interspace
immediately below the clavicle is the 1st interspace). Run your finger down the midclavicular line, over
the 2nd^ rib, to the 2nd intercostal space. Insert the IV catheter immediately above the 3rd rib. - This will release a rush of air from the pressure built up in the pleural space. Advance the catheter up
to the hub, then remove the needle stylette and discard. The patient’s ability to spontaneously breathe
usually improves immediately. Leave the catheter in place, and attach a three-way stopcock, which can
be used to drain air as it accumulates - This can improve the patient’s symptoms and be life saving. Primarily, it is fast and easy to perform,
providing enough time for the medic to set up for inserting a chest tube. The life-threatening emergency is
the tension pneumothorax, not the simple pneumothorax that remains. - Once the chest tube is properly inserted, the catheter can be removed.
Alternative Technique: Remove the plunger from a 10-20 cc syringe filled with sterile saline, attach an 18
Ga needle/catheter (or larger) and use it to perform the thoracostomy. This allows handling of the needle/IV
catheter more precisely and provides visual “bubbles” when the trapped air is released into the syringe. This
is helpful in a noisy environment. Once the catheter is placed and the needle removed, setup for chest
tube can begin. If the location is not safe for the second procedure, leave the catheter in place, attach a
three-way stopcock to drain air as it accumulates, cover the catheter with gauze and tape, and move to a
secure location for the procedure.
Tube Thoracostomy: Setup for a tube thoracostomy is more labor intensive than for a needle thoracostomy.
Perform a tube thoracostomy after or in lieu of a needle thoracostomy to treat a simple pneumothorax
(required prior to air evacuation).
- Prep the chest wall by pouring Betadine over the intended site.
- Site of insertion: along the mid-axillary line (a line running straight down from the middle of the armpit),
always above the level of nipples in males (5th intercostal space since below this level there is a risk
of puncturing the diaphragm). - Infiltrate 1% lidocaine along the track to be used. Generally, the tube is placed in the 3rd to 5th
intercostal space on the mid-axillary line. - Cut a 3 cm long incision on top of the rib, NOT in the intercostal space. Cut along the axis of the rib, down
to the bone, crossing the mid-axillary line. - Insert a large curved hemostat (Kelly Clamp) with the curve pointed toward the ribs and create a tunnel
over the top of the rib. This tunnel helps to stabilize and seal the chest tube after placement. Curve the
clamp over the top of the rib. Advance it slowly, opening and closing the jaws of the hemostat to clear a
path and then puncture into the thoracic cavity. Do not advance straight in. - Digitally explore the pleural space to remove any pleural adhesions and insure the lung is free to fall
away from the chest wall. - Have chest tube ready. Use size 28-32 French for adult pending air evacuation, 36-40°F for adult with
hemothorax, 12-14°F for children. When in doubt, use a larger size because it will allow drainage of
either air or blood from the chest cavity. Grasp the tube between the jaws of the clamp and insert into
the pleural space. Direct the clamp tip posterior, towards the apex and the spine. Make sure that the tube
is completely inserted so that no holes are left outside the chest. - Connect the free end of the chest tube to an underwater seal drainage system (Pleur-Evac), and then
suture into place with Nylon 2/0. If an underwater seal drainage system is unavailable, make a field
expedient version by securing the free end of the tube in a container of water that is lower than the
level of the inserted end of the tube. This system prevents the patient drawing air back into the chest
cavity. Bubbles coming out of the free end of the tube are a positive sign, indicating that the patient