Emergency Medicine · Year 3 · from Emergency Medicine

Case 2: Chest Tube Insertion - The Traumatic Hemothorax

Patient Demographics

  • Age: 34 years
  • Sex: Female
  • Occupation: Motorcycle enthusiast

Chief Complaint

"Motorcycle crash - she's having trouble breathing."

History of Present Illness

A 34-year-old female is brought by EMS after a motorcycle crash. She was traveling approximately 40 mph when she lost control and struck a guardrail. She was wearing a helmet but landed on her left side. She is complaining of severe left chest pain and difficulty breathing.

Initial Assessment (Trauma Primary Survey)

ESI Level: 1 - Trauma activation

First Impression:

  • Appearance: Distressed, splinting left chest
  • Work of breathing: Labored, asymmetric chest rise
  • Circulation: Pale, tachycardic

Vital Signs:

  • Heart rate: 122 bpm
  • Blood pressure: 94/62 mmHg
  • Respiratory rate: 28 breaths/min
  • SpO2: 88% on NRB
  • Temperature: Not obtained
  • GCS: 15

Primary Survey (ATLS)

A - Airway: Patent, speaking in short sentences B - Breathing:

  • Decreased breath sounds LEFT chest
  • Dullness to percussion LEFT chest
  • Asymmetric chest rise (left decreased)
  • Paradoxical movement left chest wall (flail segment)

C - Circulation:

  • Tachycardic, hypotensive
  • Weak peripheral pulses
  • JVD: Absent (hypovolemia vs. tension physiology would have JVD)

D - Disability: GCS 15, moving all extremities E - Exposure: Multiple abrasions, left chest wall deformity

Life-Threatening Thoracic Injuries Identified

  1. Hemothorax - Decreased breath sounds, dullness, hypotension
  2. Flail chest - Paradoxical chest wall movement (3+ ribs fractured in 2+ places)
  3. Possible tension physiology - Decreasing BP, desaturation

Immediate Intervention Required

Indication for Chest Tube:

  • Hemothorax in unstable patient
  • Respiratory compromise
  • Will need evacuation and monitoring of blood loss

Needle Decompression First?

  • No tracheal deviation, no JVD
  • Dull to percussion (blood, not air)
  • Proceed directly to chest tube (hemothorax)

Chest Tube Insertion - Procedure

Equipment:

  • 36 French chest tube (large bore for hemothorax)
  • Chest tube tray (scalpel, clamps, suture, sterile drapes)
  • Chest drainage system (Pleur-evac)
  • Sterile gloves, gown
  • Local anesthetic (lidocaine 1%)

Landmarks:

  • Safe triangle: Anterior border of latissimus dorsi, lateral border of pectoralis major, horizontal line at nipple level, apex below axilla
  • Insertion point: 5th intercostal space, anterior axillary line (left side)

Procedure Steps:

  1. Preparation: Sterile prep, drape, position patient (arm above head if possible)
  2. Anesthesia: Infiltrate skin, subcutaneous tissue, periosteum of rib, pleura
  3. Incision: 3-4cm horizontal incision over rib below intended interspace
  4. Dissection: Blunt dissection with Kelly clamp over superior aspect of lower rib (avoid neurovascular bundle)
  5. Pleural entry: Puncture pleura with clamp; expect rush of blood (hemothorax)
  6. Finger sweep: Confirm intrathoracic location, assess for adhesions
  7. Tube insertion: Guide tube posteriorly and superiorly using clamp
  8. Connection: Connect to drainage system
  9. Secure: Suture in place, apply occlusive dressing
  10. Confirm: Chest X-ray

Immediate Results

Initial Output:

  • 1200mL blood immediately drained (significant hemothorax)
  • Continued drainage: ~200mL/hour

Clinical Response:

  • Breath sounds improved on left
  • SpO2: 94% on NRB
  • BP: 102/68 after 1L crystalloid
  • Respiratory distress improved

Massive Hemothorax Criteria

Definition: Initial output >1500mL OR ongoing >200mL/hour for 2-4 hours

This Patient:

  • Initial output: 1200mL (significant but <1500mL threshold)
  • Ongoing: 200mL/hour - close monitoring needed

If criteria met: Surgical thoracotomy indicated

Resuscitation

Transfusion:

  • Type O negative blood initiated (2 units)
  • Type-specific blood when available
  • Massive transfusion protocol on standby

Assessment:

  • Hemoglobin: 8.2 g/dL on arrival
  • After transfusion: 10.1 g/dL

Secondary Survey

SAMPLE History:

  • Symptoms: Left chest pain, dyspnea
  • Allergies: None
  • Medications: None
  • PMH: Healthy
  • Last Meal: 2 hours ago
  • Events: MCC, 40 mph, impact to left side

Physical Exam (Secondary):

  • Head: Abrasion on helmet contact points
  • C-spine: Cleared clinically (no tenderness, full ROM, no neuro deficit)
  • Chest: Flail segment (ribs 4-7 left), chest tube in place
  • Abdomen: Soft, non-tender (FAST negative)
  • Pelvis: Stable
  • Extremities: Abrasions, no deformity

Imaging

Chest X-ray Post-Tube:

  • Chest tube in good position
  • Residual small hemothorax (improving)
  • Multiple left rib fractures (4-7) with flail segment
  • Small left pulmonary contusion
  • No pneumothorax

CT Chest:

  • Left pulmonary contusion
  • No aortic injury
  • Rib fractures confirmed
  • Residual hemothorax draining

Management

Flail Chest:

  • Pain control essential (prevents splinting, atelectasis)
  • Epidural analgesia (placed by anesthesia)
  • Incentive spirometry when able
  • Pulmonary toilet
  • Consider surgical rib fixation if severe

Chest Tube Management:

  • Monitor output hourly
  • Keep on suction (-20 cmH2O)
  • Output decreased to <50mL/hour by hour 6

Continued Resuscitation:

  • Total transfusion: 3 units PRBC
  • Hemoglobin stabilized at 10.4 g/dL

Disposition

  • Trauma ICU admission
  • Epidural for pain control
  • Chest tube to water seal day 3
  • Removed day 5 (output <100mL/24hr, no pneumothorax on clamping)
  • Transferred to floor day 6
  • Discharged day 10 with pulmonary follow-up

Teaching Points

  1. Large-bore tube for hemothorax: 28-36 French; blood is viscous
  2. Safe triangle: Know the landmarks; avoid neurovascular bundle
  3. Finger sweep is critical: Confirm intrathoracic location, assess for adhesions
  4. Massive hemothorax criteria: >1500mL initial OR >200mL/hour = surgery
  5. Autotransfusion: Blood from hemothorax can be autotransfused if available
  6. Flail chest = pulmonary contusion: Treat the underlying lung injury
  7. Pain control prevents complications: Epidural or regional anesthesia for rib fractures
  8. CXR confirms position: But procedure success is clinical (drainage, improved breath sounds)

Clinical Image

Image Description: Anatomical illustration demonstrating the safe triangle for chest tube insertion, bounded by the anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at the level of the nipple, with the apex below the axilla.

Attribution: Image from Wikimedia Commons, Chest tube insertion site. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Chest_tube_insertion.svg

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