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INTRODUCTION

A tube thoracostomy is the placement of a tube through the thoracic wall and into the pleural cavity. It is commonly referred to as a chest tube. It is placed to evacuate air, blood, or other fluid that collects within the pleural space. The etiology of the air or fluid collections can be due to iatrogenic complications, infection, lung disease, malignancy, or trauma.

Thoracic trauma accounts for nearly one-quarter of all trauma-related mortality.1,2 Some injuries require surgical intervention. Most injuries are treated nonoperatively. Injuries to the bronchi, chest wall, esophagus, lung, or trachea may lead to the presence of abnormal air and/or fluid in the pleural space. The use of a tube thoracostomy (i.e., chest tube) in these situations may be diagnostic and therapeutic. Historically, closed-tube drainage of the pleura has been used for various indications for more than a century.3 This chapter deals primarily with the use of tube thoracostomy following trauma. Much of the information remains the same regardless of whether the patient is a trauma victim or a medical patient.

ANATOMY AND PATHOPHYSIOLOGY

The diaphragm and accessory muscles of respiration contract and generate negative pressure within the pleural space on inspiration. Penetration of the visceral or parietal pleura due to injury disrupts this pressure gradient and allows air to enter the “potential space” between the pleurae and results in a pneumothorax.1,2 A simple pneumothorax is the accumulation of air that is not under pressure within the pleural space (Figure 51-1).4 It may cause the ipsilateral lung to collapse. The increased pressure in the thoracic cavity may push the mediastinum toward the noninjured side as air continues to accumulate and if there are no adhesions. This can cause angulation of the atriocaval junction, impairment of atrial filling, and a subsequent decrease in cardiac output manifest by hypotension. The presence of a pneumothorax under pressure accompanied by respiratory and/or circulatory compromise is a tension pneumothorax until proven otherwise and is an immediate life threat (Figure 51-2).

FIGURE 51-1.

Chest radiographs. A. Left-sided pneumothorax and hemothorax. B. Right-sided pneumothorax. (Used with permission from reference 4.)

There are two important points to remember about a tension pneumothorax. It is a clinical diagnosis based on the patient’s presenting signs and symptoms. Do not wait for a chest film to establish the diagnosis. The initial treatment of this entity is needle decompression or finger decompression followed by tube thoracostomy. A large-bore needle is inserted in the second intercostal space (ICS) in the midclavicular line at the superior border of the rib. A gush of air will ensue if the patient has a tension pneumothorax ...

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