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Thoracostomy

A pictorial essay on approaches and potential pitfalls

Thorakotomie

Bebilderte Anleitung zur Anlage und potenzielle Fehlerquellen

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Abstract

Background

Thoracic trauma with consecutive pneumothorax or haematothorax can be accompanied by progressive respiratory failure. If untreated, this poses the risk of develo** a life-threatening tension pneumothorax and consecutive death. Needle decompression and thoracostomy with/without chest tube insertion are therefore considered being among the final life-saving measures.

Objectives

The aim of the given work is to present the anatomical background of thoracostomy and needle decompression, and to provide an image-based compilation of the procedure and potential pitfalls, based on the new German level 3 guideline for the management of severely injured patients.

Materials and methods

Literature review, clinical intervention in cadaveric specimens, subsequent dissection and imaging.

Results and conclusions

Chest tube insertions are a suitable and effective but technically challenging procedure to treat a pneumothorax or haematothorax. Needle decompression is a simple but temporary procedure and is not considered as a measure for definite care. In the given work, the two most commonly used techniques for thoracostomy for chest tube insertion or needle decompression, namely Monaldi and Bülau, are demonstrated using radiological images, anatomical preparations and graphical illustrations. This guide illustrates thoracic and abdominal surface anatomy and shows the corresponding internal topography according to different levels, as well as the consequences of potential misplacements.

Zusammenfassung

Hintergrund

Das Thoraxtrauma mit konsekutivem Pneumothorax oder Hämatothorax geht neben einem möglichen respiratorischen Versagen mit dem Risiko einher, einen lebensbedrohlichen Spannungspneumothorax zu entwickeln, der unbehandelt zum Tod führen kann. Die Nadeldekompression und Thorakotomie mit/ohne Anlage einer Thoraxdrainage gehören zu den endgültigen bzw. lebensrettenden Maßnahmen.

Fragestellung

Ziel der Arbeit ist es, die anatomischen und klinischen Hintergründe zur Thorakotomie und Dekompression darzustellen und eine bildgestützte Zusammenstellung der Vorgehensweise und möglicher Fallstricke aufzuzeigen. Die Beschreibung und Darstellung berücksichtigt auch die aktuelle Version der deutschen S3-Leitlinie „Polytrauma/Schwerverletzten-Behandlung“.

Material und Methoden

Literatur- und Bildauswahl, Darstellung der klinischen Intervention an Körperspendern der Anatomie.

Ergebnisse und Diskussion

Die Anlage der Thoraxdrainage ist eine geeignete und wirksame, aber technisch schwierige und daher komplikationsbehaftete Maßnahme. Die Nadeldekompression ist eine einfache, aber nur vorübergehende Maßnahme und stellt keine definitive Versorgungsoption dar. Diese Arbeit zeigt die beiden am häufigsten verwendeten Techniken (Monaldi- und Bülau-Drainage) zur Thorakotomie bei Anlage der Thoraxdrainage oder Nadeldekompression anhand von radiologischer Bildgebung, anatomischen Präparaten und Grafiken. Die Anleitung weist auf mögliche Fehlanlagen und die Zuordnung der entsprechenden Oberflächenanatomie zur inneren Thorax- und Abdominaltopographie hin.

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Acknowledgements

The authors express their gratitude to the body donors for donating their corpses for teaching and research projects after passing away. The authors also thank their families for supporting their valuable decision. We also thank Matthias Oehme and Thomas Wolfskämpf with the prosections. Christine Auste took the images and Robbie McPhee draw the illustrations forming an integral part of this pictorial essay.

Author information

Authors and Affiliations

  1. Department of Anatomy, University of Otago, Great King Street 270, 9016, Dunedin, New Zealand

    N. Hammer M.D.

  2. Institute of Anatomy, University of Leipzig, Leipzig, Germany

    N. Hammer M.D.

  3. Faculty of Medicine, Eberhard Karls University Tübingen, Tübingen, Germany

    D. Häske

  4. Department of Orthopaedics, Trauma and Reconstructive Surgery, University Clinic of Leipzig, Leipzig, Germany

    A. Höch

  5. Institute of Forensic Medicine, University of Leipzig, Leipzig, Germany

    C. Babian

  6. Department of Anesthesiology and Intensive Care Medicine, Section Emergency Medicine, Federal Armed Forces Medical Hospital, Ulm, Germany

    B. Hossfeld

  7. Division of Neuroradiology, University Clinic of Leipzig, Leipzig, Germany

    P. Voigt

  8. Department of Neurosurgery, University Clinic of Leipzig, Leipzig, Germany

    D. Winkler

  9. Emergency Department, University Hospital of Leipzig, Leipzig, Germany

    M. Bernhard

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Correspondence to N. Hammer M.D..

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N. Hammer, D. Häske, A. Höch, C. Babian, B. Hossfeld, P. Voigt, D. Winkler and M. Bernhard declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Hammer, N., Häske, D., Höch, A. et al. Thoracostomy. Notfall Rettungsmed 21, 212–224 (2018). https://doi.org/10.1007/s10049-017-0315-5

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