The chest-tube thoracostomy

Indication. Symptomatic traumatic haemothorax, or haemothorax over 500 mL, should be treated by chest-tube insertion (de Lesquen, Grade D). Occult haemothoraces may be observed with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B).^[1]

Landmarks. Exam teaching uses the mid-axillary safe triangle at about the fourth or fifth intercostal space. That landmark is not a blank cheque: in paediatric emergency patients the diaphragm crossed into or above the fifth ICS in 10.3 per cent during tidal respiration and 27.2 per cent during maximal respiration (45 per cent of right hemidiaphragms at maximal respiration). Confirm the space with ultrasound, especially in children and at higher BMI.^[3]

Steps. (1) Time-out for side. (2) Skin preparation and local anaesthetic in the conscious patient — milligram-per-kilogram lidocaine ceilings are local protocol, not a quote from these papers. (3) Incision parallel to the rib over the upper border of the lower rib (neurovascular bundle in the subcostal groove). (4) Blunt dissection; no trocar. (5) Finger sweep to confirm pleural entry and clear adhesions. (6) Tube directed toward the collection; underwater seal; suture and dressing. (7) Chest radiograph. Watch output: damage-control thoracotomy if output exceeds 1500 mL initially or 200 mL/h for 3 hours with refractory shock (Grade D).^[1]

Retained haemothorax. If clot remains, the AAST study (328 patients, 20 centres) found VATS the most common first procedure (33.5 per cent); 20.4 per cent ultimately needed thoracotomy; retained volume of 300 mL or less predicted successful observation. Early VATS in stable patients is Grade B in the blunt-chest review.^[2][1]

Complications. Empyema and pneumonia (the reason for periprocedural antibiotics and for not leaving retained blood), intercostal-vessel bleeding, malposition, subcutaneous emphysema, and — if the fifth-space landmark is used blindly in a child — diaphragmatic or intra-abdominal injury.^[1][3]