incision is made at the fifth rib between the mid and anterior axillary lines (Figure 7-1A). Using a large curved

clamp, tunnel up through the soft tissues over the fifth rib

to the fourth to fifth intercostal space. Then, using the

same clamp, puncture through the intercostal muscles,

using care not to enter the pleural space too deeply (Figure

7-1B). Open the jaws of the clamp to widen the hole in the

intercostal muscles. Insert a gloved finger through the tract

into the pleural cavity, using the curved clamp as a guide,

and then remove the clamp. Using your finger, ensure there

are no lung adhesions (Figure 7- 1 C). Using your finger or

the curved clamp, insert the chest tube into the thorax,

directing the tube posterior and superior, ensuring that all

the evacuation holes of the tube are within the thorax

(Figure 7- lD). The tube is then attached to a suction

device (Figure 7-2). Secure the tube by placing a simple

interrupted suture inferior to the tube. After tying a knot,

the remaining suture should be wrapped around the t ube

several times and a second knot tied. The skin above the

tube should then be closed with simple interrupted sutures.

Cover the wound with Vaseline gauze and a bandage. A

postprocedure chest x-ray should be ordered to check tube

position and confirm lung reexpansion (Figure 7-3).

COMPLICATIONS

The most common complication of needle thoracostomy

is failure to decompress. The patient's body habitus should

dictate the size of the catheter over needle being used. If a

.A. Figure 7-3. Chest x-ray showing the proper position

of a chest tube in the right lung.

3-cm catheter over needle fails to reach the pleural space,

the procedure should be immediately repeated with a

4.5-cm catheter over needle.

Infection remains a serious complication of tube thoracostomy for patients with chest trauma, with incidences

ranging from 2o/o to 25%. Thus strict sterile technique

should always be followed. Tubes should never be

advanced back into the thoracic cavity if they have

migrated out. A new tube should be placed. Bleeding can

also complicate tube thoracostomy. It may occur from

superficial venules or arterioles at the incision site or

from iatrogenic injury to the lung or abdominal organs.

Incorrect tube placement may cause kinking, subcutaneous placement, or evacuation holes remaining outside the

thoracic cavity, which results in either a nondraining tube

or one with a persistent air leak. Reexpansion pulmonary

edema, a rare but life-threatening complication, is more

common when the lung has been completely collapsed

for several days. Avoid this complication by placing the

tube to water seal after insertion if the lung has been collapsed for a prolonged period. This allows for a more

gradual reexpansion.

SUGGESTED READING

Brunett PH, et al. Pulmonary trauma. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1, pp.

1 744-1 758.

Joseph KT. Tube thoracostomy. In: Reichman EF, Simon RR.

Emergency Medicine Procedures. 1st ed. New York, NY:

McGraw-Hill, 2004, pp. 226-236.

Introduction to Emergency

U ltrasonography

john Bail itz, MD

Basem F. Khishfe, MD

Key Points

• use of ultrasound by emergency physicians has grown

significantly in the last decade.

• Emergent appl ications include the setting of trauma,

abdominal aortic aneurysm, ectopic pregnancy, gall

bladder, and kidney and as an aid to procedures (eg,

intravenous access).

INDICATIONS

Emergency ultrasound (EUS) is preformed by emergency

physicians at the patient's bedside to rapidly answer an

increasing number of focused diagnostic questions, safely

guide invasive procedures, and monitor the response to

treatment. The 2008 American College of Emergency

Physicians ultrasound guidelines describe the history and

training process for the now 11 core EUS applications. EUS

is most commonly used to evaluate and manage patients

with the following clinical presentations:

Abdominal and chest trawna. The Focused Assessment

with Sonography for Trauma (FAST) exam evaluates

for blood in the pericardial, pleural, and peritoneal

compartments in a rapid, reproducible, portable,

and noninvasive approach. The extended FAST exam

evaluates for evidence of pneumothorax.

Ectopic pregnancy. Abdominal/pelvic pain or vaginal

bleeding are common presentations in the first trimester.