How do I insert a chest tube in a trauma patient with crackles and crepitus to the right upper lobe?

Chest Tube Insertion for Trauma Patient with Pneumothorax

For a trauma patient with crackles and crepitus in the right upper lobe, you should immediately insert a chest tube in the "safe triangle" of the chest wall using proper sterile technique to evacuate the likely pneumothorax and prevent tension pneumothorax. 1

Pre-Insertion Assessment and Preparation

• Crackles and crepitus in the right upper lobe strongly suggest pneumothorax with subcutaneous emphysema, requiring immediate intervention 2
• Gather all necessary equipment: sterile gloves, gown, appropriately sized chest tube (small-bore 8-12 FG if possible), sterile towels, antiseptic solution, local anesthetic, suture material, and chest drainage system 1
• Position the patient appropriately - slightly rotated with arm on affected side behind head to expose the axillary area 1
• Use full sterile technique to prevent infection or secondary empyema 1

Insertion Procedure

1. Identify the insertion site in the "safe triangle" bordered by:

   • Anterior border of latissimus dorsi
   • Lateral border of pectoralis major
   • Line horizontal to the nipple 1

2. Administer local anesthesia:

   • Inject at the insertion site and down to the pleura
   • Use adequate anesthesia to minimize patient discomfort 1

3. Make the incision:

   • Create a small incision at the predetermined site, large enough to accommodate the chest tube
   • The incision should be slightly larger than the tube diameter 1

4. Insert the chest tube:

   • Never use substantial force or a trocar during insertion as this risks sudden chest penetration and damage to intrathoracic structures 1, 3
   • Bluntly dissect through subcutaneous tissues and intercostal muscles
   • Use your finger to create a path into the pleural space and confirm entry
   • Direct the tube posteriorly and superiorly for air (pneumothorax) 1

5. Secure the tube:

   • Close the incision with a non-absorbable suture around the chest tube
   • Apply a stay suture through the skin and criss-cross up the drain 1, 3
   • Apply sterile dressing around the insertion site 1

6. Connect to drainage system:

   • Connect to a unidirectional flow drainage system (underwater seal)
   • Keep the system below the level of the patient's chest at all times 3
   • Never clamp a bubbling chest tube as this may convert a simple pneumothorax into a tension pneumothorax 3

7. Confirm placement:

   • Obtain a chest radiograph to confirm proper tube position and effectiveness 1, 3
   • Look for equal bilateral chest wall expansion with ventilation 1

Post-Insertion Management

• Record the depth of tube insertion prominently in the patient's chart 1
• Monitor for respiratory swing in the fluid level of the chest tube to assess tube patency 3
• Watch for development of surgical emphysema, which may occur with malpositioned, kinked, or blocked tubes 3
• Provide adequate analgesia - consider intercostal nerve blocks or intrapleural local anesthetic 3
• Maintain chest tube patency without breaking the sterile field 3

Common Pitfalls and How to Avoid Them

• Using excessive force during insertion - Always insert the tube gently to avoid damage to intrathoracic structures 1, 3
• Inadequate securing of the tube - Ensure the tube is well-secured to prevent accidental dislodgement 1, 3
• Failure to obtain post-procedure imaging - Always get a chest radiograph after insertion to confirm proper placement 1, 3
• Clamping a bubbling chest tube - This can convert a simple pneumothorax into a life-threatening tension pneumothorax 3
• Breaking sterile technique - Maintain aseptic technique throughout to prevent infection 3

Special Considerations for Trauma Patients

• In trauma patients, pneumothorax is common and requires prompt intervention to prevent deterioration 4, 5
• If tension pneumothorax is suspected (with rapid deterioration, cyanosis, tachycardia), first perform needle decompression in the second intercostal space mid-clavicular line before chest tube placement 2
• Small-bore chest tubes (10-14F) are appropriate for most pneumothoraces, with larger tubes only considered when there is persistent air leak or pleural fluid 3, 4
• Refer to a respiratory physician if the pneumothorax fails to respond within 48 hours to treatment 3