Breathing - Thoracostomy (open)
Traumatic cardiac arrest (bilateral starting on injured side)
Failed needle thoracostomy in tension pneumothorax
Contraindications (absolute in bold)
Small intercostal catheter (Seldinger technique)
Large intercostal catheter (blunt dissection size 24-32Fr)
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
Failure to decompress
Neurovascular, visceral and pulmonary parenchymal damage
Occlusion with recurrence of tension pneumothorax (requiring re fingering)
Surgical aseptic non-touch technique
PPE: double sterile gloves (if performing finger sweep), sterile surgical gown, surgical mask, eye protection
Procedural clinician and assistant
Clamp (Howard Kelly or equivalent)
On the bed with head elevated to 45 degrees
Arm on the side of the lesion behind the patient’s head (abducted and externally rotated)
Supine with arm out to the side on side of lesion (crucifix position)
Locate safe triangle: lateral to pectoralis major, medial to latissimus dorsi, fourth or fifth intercostal space, anterior to mid-axillary line
With the arm by the side, mark the anterior mid-arm point from shoulder tip to antecubital fossa (preferred), or
Place your open hand in the axilla and mark the edge of the hand between the anterior and mid-axillary line, or
Palpate the second intercostal space at the sternal angle, move down two spaces and palpate space around to the axilla
It is common for incisions to be too low in the chest, with risk of visceral injury
Place an intercostal space higher in pregnant patients due to increased elevated diaphragm
20ml lignocaine 1% with adrenaline (1:100,000)
Cephazolin IV 2g
Ketamine IV 10-20mg (pain relief pre-procedure adjusted to co-morbid status)
Morphine IV 5-10mg (opioid pain relief pre-procedure adjusted to co-morbid status)
Midazolam IV 1-2mg (anxiolytic pre-procedure adjusted to co-morbid status)
Anaesthetise skin, soft tissue, muscle and periosteum (unless arrested or peri-arrest)
Incise 4cm just above and parallel with the upper border of rib at insertion site (avoiding neurovascular bundle)
Hold clamp with only 4cm exposed distal to fingers to reduce chance of lung injury
Push clamp slightly upwards through muscle to enter the pleural space with likely ‘give’ and ‘gush’ of air or blood
Open clamp slightly with likely further ‘gush’ of air or blood, then close
Rub clamp side to side on superior margin of rib below to bluntly dissect a hold large enough for a chest drain
Palpate through thoracotomy with little finger, opening tract and confirming position in thoracic cavity (optional)
Perform a finger sweep of pleura around thoracostomy excluding pleural adhesions (optional)
Immediate large intercostal catheter (unless intubated, ventilated and heading directly to theatre)
Antibiotics (2g cefazolin)
Document procedure (completion, technique and any immediate complications)
Palpate rib borders prior to incision, orienting yourself to the anatomy (ribs angle inferiorly as you move anterior)
Locating landmarks by mid-arm point is evidence-based and our recommended method
Skin markings made at the mid-arm point move slightly superior with abduction, still incise at the marking
Immediate catheter placement is indicated after thoracostomy in a spontaneously breathing patient
Antibiotics and good aseptic technique reduce the significant risk of infection (empyema and pneumonia)
The triangle of safety is the key landmark. A significant proportion of chest drains and thoracostomies are placed outside of this area due to procedural error. Of the various methods for determining correct position of placement, rapid measurement of mid-arm point appears the most practical and accurate and is our preferred method.
Making an oblique track slightly upwards (<45 degrees) and through the intercostal space reduces the risk of chest tube placement in the lung fissure, which is associated with increased failure requiring replacement. We advocate entering the rib space low to enable an oblique path to be formed.
The finger sweep is a useful part of chest tube placement, confirming position in the thoracic cavity, maintaining the track and excluding lung and pleural adhesions (which increase the risk of parenchymal injury and fissure placement). The finger sweep carries a risk of sharps injury to the proceduralist if broken ribs are present. We advocate a cautious finger sweep using double gloves for increased sharps protection. Easily disrupted adhesion should be lysed with the finger. Firm adhesions require an alternative site of tube placement. The finger sweep should be omitted in trauma patients suspected to be at high risk of blood-borne pathogens (hepatitis B, C or HIV). The proceduralist is required to make this judgement at the bedside and is it acceptable for providers to choose to always omit a finger sweep in trauma due to risk of sharps injury.
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Greater Sydney Area Helicopter Emergency Service
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 11.10 – resuscitation in special circumstances. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2010. 14pp. Available from https://resus.org.au/guidelines/
Ambulance Service of NSW. Blunt thoracic trauma. Report HELI.CLI.09. Sydney: ASNSW; 2013. 5pp. Available from: https://sydneyhems.com/resources/policies-and-procedures/
NSW Agency for Clinical Innovation. Consensus guideline: pleural drains in adults. Sydney: ACI; 2016. 55pp. Available from: https://www.aci.health.nsw.gov.au/resources/respiratory/pleural-drains/pleural-drains-in-adults
Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159-173. doi:10.1097/TA.0000000000000648
Henry M, Arnold T, Harvey J; Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the management of spontaneous pneumothorax. Thorax. 2003;58 Suppl 2(Suppl 2):ii39-ii52. doi:10.1136/thorax.58.suppl_2.ii39
MacDuff A, Arnold A, Harvey J on behalf of the BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii18:1131. Available from: https://thorax.bmj.com/content/65/Suppl_2/ii18.
Royal Perth Bentley Group. Occult pneumothorax (OPTX) patients presenting for surgery management: clinical guideline (RPH). Perth: Government of Western Australia Eastern Metropolitan Health Service; 2014. 4pp. Available from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/426293/Trauma_Occult-Pneumothorax-OPTX-Patients-Presenting-for-Surgery-Management.pdf.
Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.
American College of Surgeons. Advanced trauma life support Student Course Manual. 9. American College of Surgeons; Chicago: 2012.
Huggins JT, Carr S, Woodward GA. Placement and management of thoracostomy tubes and catheters in adults and children. UpToDate, 7 May 2020. Available from: https://www.uptodate.com/contents/placement-and-management-of-thoracostomy-tubes-and-catheters-in-adults-and-children.
Laan DV, Vu TD, Thiels CA, Pandian TK, Schiller HJ, Murad MH, Aho JM. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016;47(4):797-804. doi:10.1016/j.injury.2015.11.045.
Fitzgerald M, Mackenzie CF, Marasco S, Hoyle R, Kossmann T. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008;39(1):9-20. doi:10.1016/j.injury.2007.07.021.
Butson B, Kwa P. Intercostal catheter insertion. Emerg Med Australas 2015 Feb;27(1):66-8. doi: 10.1111/1742-6723.12347. Epub 2015 Jan 8.
Carter P, Conroy S, Blakeney J, Sood B. Identifying the site for intercostal catheter insertion in the emergency department: is clinical examination reliable?. Emerg Med Australas. 2014;26(5):450-454. doi:10.1111/1742-6723.12276.
Bing F, Fitzgerald M, Olaussen A, Finnegan P, O’Reilly G, Gocentas R, Stergiou H, Korin A, Marasco S, McGiffin D. Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP): Journal of Emergency Medicine, Trauma and Acute Care: 2017:1 http://dx.doi.org/10.5339/jemtac.2017.3.
Hernandez MC, El Khatib M, Prokop L, Zielinski MD, Aho JM. Complications in tube thoracostomy: Systematic review and meta-analysis. J Trauma Acute Care Surg. 2018;85(2):410-416. doi:10.1097/TA.0000000000001840.
Hernandez MC, Laan DV, Zimmerman SL, Naik ND, Schiller HJ, Aho JM. Tube thoracostomy: Increased angle of insertion is associated with complications. J Trauma Acute Care Surg. 2016;81(2):366-370. doi:10.1097/TA.0000000000001098.
Kim YW, Byun CS, Cha YS, Kim OH, Lee KH, Park IH. Differential outcome of fissure-positioned tube in closed thoracostomy for primary spontaneous pneumothorax. Am Surg. 2015;81(5):463-466.
Sanabria A, Valdivieso E, Gomez G, Echeverry G. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies. World J Surg. 2006;30(10):1843-1847. doi:10.1007/s00268-005-0672-y.