This self instructional unit is designed for 

use with the medical student who has completed 

or is taking gross anatomy.

There are a number of ways to perform this procedure.

We are demonstrating only one technique 

upon completion of this unit,

you should be able to: one: list and 

sequence nine key steps for performing the 

closed chest tube thoracotomy. Two: 

locate either on yourself or another person.

The exact position for the superficial 

incision and the exact position for the chest 

wall puncture.

Three,

you will be shown a different recording of the same 

procedure while observing this second 

operation list,

all departures from the recommended procedure 

and which of the nine key steps are 

omitted.

This is a middle aged male who has suffered a 

penetrating wound to the chest.

The X ray demonstrates a significant hemo 

pneumothorax which will require a closed 

tube thoro to expand the collapsed 

lung.

The patient is placed in the right lateral decubitus 

position with the left upper extremity 

extended over the head.

The tube will be placed in the fifth intercostal 

space in the anterior axillary line.

A scar from a previous chest tube can be seen.

The chest is shaved and prepared in a routine 

fashion with IO to four solution.

A sterile ice sheet is placed over the site 

chosen for the skin incision.

A 25 gauge needle is used to make a 

small skin wheel at sight of the 

incision.

A large needle is used to anesthetize 

the subcutaneous tissue of the whole area.

Then the muscles and the plea of the 

fourth intercostal space are 

anesthetized 

after the anesthetic has taken effect.

A transverse decision is made at the 

fifth intercostal space.

This incision,

four centimeters in length is extended through 

the subcutaneous tissue down to the muscle.

The fourth intercostal space superior to the 

incision is then identified.

A kelly clamp is then used to bluntly 

dissect through the muscle layers 

and puncture.

The parietal pleura 

care must be taken to avoid injury to 

the lung when entering the pleural cavity.

In this diagrammatic coronal section 

of the left chest,

we can see that by entering the plural space,

one intercostal space higher than the skin 

incision.

A subcutaneous tunnel is created which 

helps to prevent air leaks around the chest tube.

Also the occlusion of this tunnel when the tube is 

removed will prevent the entrance of air 

into the plural space.

Using the finger,

we then verify complete penetration of the 

parietal pleura and the separation of 

the lungs,

visceral and the parietal pleura.

This is a 32 gauge plastic 

chest tube which has numerous holes 

placed circumferentially around the blunt tip 

the blunt end of the tube is gripped by the Kelly 

clamp.

And after the previously created 

tunnel is located,

the tube is introduced into the plural cavity.

The clamp is withdrawn as soon as the tube is 

within the plural space.

The tube is positioned posteriorly 

and its tip is directed toward the apex of the 

plural cavity.

As seen in this X ray.

A clamp is used to prevent premature drainage of 

the blood from the plural cavity and to 

prevent additional air from entering 

the tube is placed at the medial end of the incision 

and interrupted sutures are used to close the 

lateral incision.

Then a purse string suture is placed around the 

chest tube.

This will be tied only after the chest tube 

has been removed,

loose ends of the purse string are 

rolled around the suture package and 

positioned against the chest wall.

The ice sheet is then removed 

of benzoin is applied to enhance 

adhesiveness and to prevent skin 

irritation.

When the tube is taped to the chest wall.

A gauze sponge with a Y shaped 

incision is placed around the base of the 

chest tube and 

taped in place.

The chest tube is then secured to the chest 

wall to prevent accidental 

removal.

Taping the tube close will also 

help to prevent irritation when the patient 

moves.

The tube is then attached to a drainage 

system 

and each connection is securely taped.

The clamp is removed from the tube 

and the trapped blood and air are allowed to 

escape from the left plural space 

into the two bottle drainage system.

The water sealed trap bottle on the left 

collects the blood and air.

The control bottle provides for a regulated 

negative suction on the water seal 

bottle.

To facilitate plural cavity drainage.

The center tube should be adjusted to between 

10 and 20 centimeter column of water.

A self evaluation period follows.

Please respond as requested 

on a sheet of paper list.

In sequential order,

the nine key steps for performing the closed 

chest tube.

Thom,

your answer should have been one.

Locate the puncture site.

The fifth intercostal space in the 

anterior axillary line,

two,

prepare the operation site.

Three,

administer the local anesthetic.

Four,

make superficial incision over the fifth 

intercostal space.

Five,

make chess wall dissection through the fourth 

intercostal space 

six.

Verify complete dissection with the finger 

seven,

insert the chest tube,

eight,

secure the chest tube.

Nine connect the chest tube to the 

drainage system.

Locate either on yourself another 

person or on the TV.

Monitor the exact position for 

the incision and the exact position 

for the chest wall puncture.

First,

we locate and mark the anterior axillary 

line.

Then we palpate the joint between 

the manubrium and the body of the sternum.

This indicates the second rib.

The first interspace is just above,

we then count down to the fifth 

interspace.

The incision will be made at the fifth 

intercostal space in the anterior 

axillary line and the chest wall 

puncture will be made superior to the 

incision in the fourth intercostal space.

You will now see a different recording of a 

closed chest tube thot 

while observing this operation.

Please list all the departures from the 

recommended procedures and which of the nine 

key steps have been omitted.

There will be no sound on this portion.

Now,

let's see how well you have done.

First of all,

the patient is not in the right lateral decubitus 

position.

And although the physician has determined the incision 

site,

he does not compare it with any anatomical 

landmark.

Draping of the operation site is not complete 

as a sterile ice sheet has not been 

used.

The anesthetic is not administered to the 

deeper tissues.

Scissors are used for the blunt dissection.

The dissection is not properly verified with the 

finger.

Although the space between the ribs can be felt,

the tissues have evidently not been properly 

dissected as four attempts to 

insert the tube meet with failure.

Finally,

the finger is inserted deep enough to complete the 

dissection.

But even now,

the separation of the visceral and the parietal 

pleura is not verified.

Vaseline gauze is placed directly over 

the wound.

This is not necessary as 

suturing has closed the tunnel and the 

Vaseline gauze hinders healing and 

affords a place for bacteria and germ 

growth.

The control bottle of the two bottle drainage 

system has not been 

connected to a vacuum