[Damage of the subclavian vein with a thorax drainage]

Thoracoacromial artery injury after tube thoracostomy for pneumothorax

In this case, a patient presented in a delayed fashion after blunt trauma is found to have a large left-sided pneumothorax, and tube thoracostomy is performed. After placement of the apically oriented tube, he developed haemothorax. CT imaging showed an area of questionable extravasation from the left subclavian artery, directly anterior to the thoracostomy tube. His haemothorax was refractory to adequate drainage with a new thoracostomy tube. He ultimately required angiography, coil embolisation and covered stent placement, followed by thoracoscopic evacuation of the haemothorax.

Misadventures of a Pigtail: Case Report of Accidental Insertion of a Chest Tube Into the Left Atrium During Interventional Radiology-Guided Placement

Chest tube thoracostomy is a commonly performed procedure in the emergency department, operating room, and intensive care unit. We report an extremely rare case of accidental insertion of a chest tube into the left atrium via the right pulmonary vein during an interventional radiology-guided placement of the catheter. To our knowledge, such a case has not been reported to date. The anesthetic and surgical management of this injury are discussed.

[Chest decompression in emergency medicine and intensive care]

Decompression of the chest is a life-saving invasive procedure for tension pneumothorax, trauma-associated cardiopulmonary resuscitation or massive haematopneumothorax that every emergency physician or intensivist must master. Particularly in the preclinical setting, indication must be restricted to urgent cases, but in these cases chest decompression must be executed without delay, even in subpar circumstances. The methods available are needle decompression or thoracentesis via mini-thoracotomy with or without insertion of a chest tube in the midclavicular line of the 2nd/3rd intercostal space (Monaldi-position) or in the anterior to mid-axillary line of the 4th/5th intercostal space (Bülau-position). Needle decompression is quick and does not require much material, but should be regarded as a temporary measure. Due to insufficient length of the usual 14-gauge intravenous catheters, the pleural cavity cannot be reached in a considerable percentage of patients. In the case of mini-thoracotomy, one must be cautious not to penetrate the chest inferior of the mammillary level, to employ blunt dissection techniques, to clearly identify the pleural space with a finger and not to use a trocar. In extremely urgent cases opening the pleural membrane by thoracostomy without inserting a chest tube is sufficient in mechanically ventilated patients. Complications are common and mainly include ectopic positions, which can jeopardise effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as haemorrhage or infections. By respecting the basic rules for safe chest decompression many of these complications should be avoidable.

Thoracostomy tubes: A comprehensive review of complications and related topics

Tube thoracostomy (TT) placement belongs among the most commonly performed procedures. Despite many benefits of TT drainage, potential for significant morbidity and mortality exists. Abdominal or thoracic injury, fistula formation and vascular trauma are among the most serious, but more common complications such as recurrent pneumothorax, insertion site infection and nonfunctioning or malpositioned TT also represent a significant source of morbidity and treatment cost. Awareness of potential complications and familiarity with associated preventive, diagnostic and treatment strategies are fundamental to satisfactory patient outcomes. This review focuses on chest tube complications and related topics, with emphasis on prevention and problem-oriented approaches to diagnosis and treatment. The authors hope that this manuscript will serve as a valuable foundation for those who wish to become adept at the management of chest tubes.