急診胸管放置－~Teachingcenter的醫學筆記~

※若是對此項技術有不明確者，請務必找資深住院醫師或主治醫師協助

適應症與禁忌症
A. 胸管放置適應症：
= 氣胸>20%或距離肺尖(apex)大於2公分
-- Pneumothorax (spontaneous, tension, iatrogenic, traumatic)
= 肺部積液(為了將水、膿、血、乳糜等引流出)
※血胸如果瞬間出來大於20mL/kg、連續三小時每小時出來200mL、持續輸血48小時仍低Hb，請手術處理
-- Pleural collection - Pus ( empyema), blood (hemothorax), chyle ( chylothorax)
= (胸腔、上腹腔)手術術後
-- Postoperative
-- Thoracotomy, Video-assisted thoracoscopic surgery (VATS)
= 中央靜脈導管放置之併發症
-- Complication of central venous catheter placement
B. 胸管放置相對禁忌症(無絕對禁忌症)：
= 前次胸管治療失敗
= 有過胸腔手術病史
= 出血傾向高
= 胸腔嚴重感染
C. 外傷氣胸病人若為以下狀況，可以考慮暫不插胸管：
= 單純氣胸無明顯血胸occult or simple pneumothorax
= 血行動力穩定無呼吸窘迫hemodynamic stable without respiratory distress
= 沒有需要正壓呼吸(呼吸器、或全身麻醉)需求或計畫no need of ventilation or general anesthesia
= 有密集的監控intensive care and monitoring

胸腔放置技術執行
A. 執行前準備
= 詳細解釋技術的適應症、簽署同意書與其風險
-- Obtain informed consent and well explained risk
= 將病人平躺，要放置胸管側的上肢移到頭部之上
-- Patient preparation: Insertion side up with ipsilateral arm over head
= 將所需物品備好擺妥(胸管28~32#、11#刀片、止血鉗、局部麻醉藥(10mL空針)、縫合包(3-0 nylon or silk)、紗布、胸瓶)
-- Chest tube 28~32# for traumatic patient, 11# blade or scalpel, Kelly, xylocaine (10mL needle), suture set with 3-0 nylon or silk, gauze, chest bottles
= 用水性優碘於第五肋間和液中線區域滅菌
-- Disinfect 5th intercostals space / anterior axillary line
※第四肋和第五肋肋間，可以從第二肋間(sternomanubrial joint)往下算，也可以直接估於乳頭沿線處
※胸管三角(安全三角) Chest tube triangle (safe triangle)
-- 下：乳頭水平線(Nipple line)
-- 前：胸大肌(Pectoralis major muscle)後緣
-- 後：闊背肌(Latissimus dorsi muscle)前緣
B. 技術執行(帶起無菌手套)
= 將胸管末端夾起，避免技術執行時擠入更多的空氣
-- Clamp chest tube distal end with Kelly clamp
= 於預計放置處做適當的局部麻醉(需麻醉至肋膜，可由選定之肋骨的上緣進針麻醉)
-- Apply proper local anesthesia in previous sterilized area from skin through the tract you’ll create and until pleura ( usually through the margin just above selective rib)
= 用刀片將皮膚劃開
-- With 11# blade to create wound including subcutaneous tissue for allow subsequent blunt dissection
= 在傷口角落留一針Mattress suture (也可以在放完胸管後執行此步驟)
-- Mattress suture over wound corner
= 用止血鉗擴張傷口並且突入胸腔(手指能摸到肺臟為佳)
-- Blunt serial dissect by Kelly clamp, with steady and controlled pressure, push through parietal pleura, then carefully widening the pleural hole
= 用手指確認預計放置胸管處周圍沒有過多的肺臟組織沾黏
-- Index finger blunt dissection followed
= 將胸管放過肋膜後，沿著外上側方向放置(可用Kelly做輔助)
-- Direct the chest tube inferiorly, laterally then superiorly through the tract
= 連接胸管和胸瓶，並且觀察是否有空氣血水流出，或胸瓶水面是否有波動
-- Connect chest tube with bottles and watch for water column in fluctuation and/or air/blood drainage function
= 將胸管固定(可以用先前留下的Mattress)
-- Tie the ends of suture around tube snugly
= 將胸管以抗菌敷料和布膠蓋好後，照CXR確定位置
-- Cover the tube and obtain CXR