The remainder of this Unit contains details of procedures which, although not described in detail in the Annex: Primary Trauma Care Manual, may be needed in the management of severely injured patients.

INSERTION OF CHEST DRAIN AND UNDERWATER SEAL DRAINAGE

Indications for underwater-seal chest drainage are:

Technique

1	Prepare the skin with antiseptic and infiltrate the skin, muscle and pleura with 1% lidocaine at the appropriate intercostal space, usually the fifth or sixth, in the midaxillary line (Figure 16.2). Note the length of needle needed to enter the pleural cavity; this information may be useful later when you are inserting the drain.
Figure 16.2
2	Aspirate fluid from the chest cavity to confirm your diagnosis (Figure 16.3).
Figure 16.3
3	Make a small transverse incision just above the rib to avoid damaging the vessels under the lower part of the rib (Figures 16.4, 16.5). In children, it is advisable to keep strictly to the middle of the intercostal space.
Figure 16.4
Figure 16.5
4	Using a pair of large, curved artery forceps, penetrate the pleura and enlarge the opening (Figures 16.6, 16.7). Use the same forceps to grasp the tube at its tip and introduce it into the chest (Figures 16.8, 16.9).
Figure 16.6
Figure 16.7
Figure 16.8
Figure 16.9
5	Close the incision with interrupted skin sutures, using one stitch to anchor the tube. Leave an additional suture untied adjacent to the tube for closing the wound after the tube is removed. Apply a gauze dressing.
6	Connect the tube to the underwater-seal drainage system and mark the initial level of fluid in the drainage bottle (Figure 16.10).
Figure 16.3

Aftercare
Place a pair of large artery forceps by the bedside for clamping the tube when changing the bottle. The drainage system is patent if the fluid level swings freely with changes in the intrapleural pressure. Persistent bubbling over several days suggests a bronchopleural fistula and is an indication for referral.

Change the connecting tube and the bottle at least once every 48 hours, replacing them with sterile equivalents. Wash and disinfect the used equipment to remove all residue before it is resterilized.

If there is no drainage for 12 hours, despite your “milking” the tube, clamp the tube for a further 6 hours and X-ray the chest. If the lung is satisfactorily expanded, the clamped tube can then be removed.

To remove the tube, first sedate the patient and then remove the dressing. Clean the skin with antiseptic. Hold the edges of the wound together with fingers and thumb over gauze while cutting the skin stitch that is anchoring the tube. Withdraw the tube rapidly as an assistant ties the previously loose stitch.

TRACHEOSTOMY

The indications for tracheostomy are:

The surgical management of an acute airway obstruction is an emergency cricothyroidotomy (see the Annex: Primary Trauma Care Manual, pages PCTM–5 and 6.

Technique for elective tracheostomy

1	Place the patient supine on a table or bed. Extend the neck by placing a sandbag (or a rolled towel for infants and children) under the shoulders (Figure 16.11).
Figure 16.11
2	Prepare the skin with antiseptic and infiltrate local anaesthetic into the skin from the suprasternal notch along the midline to the thyroid cartilage (Figure 16.12).
Figure 16.12
3	Palpate the cricoid cartilage to ascertain its position (Figure 16.13) and make a midline incision between its inferior border and the superior margin of the suprasternal notch (Figures 16.14, 16.15).
Figure 16.13
Figure 16.14
Figure 16.15
4	Separate the strap muscles from the midline by blunt dissection (Figure 16.16) to expose the trachea with the thyroid isthmus lying anterior to it. Retract the isthmus either upwards or downwards, or divide it between artery forceps and ligate the ends (Figures 16.17, 16.18). Divide and retract the pretracheal fascia (Figure 16.19) to expose the second and third tracheal cartilages. Then lift and steady the trachea with small skin-hook retractors. • In infants and children, make a transverse intercartilaginous incision between the second and third rings (Figure 16.20). Avoid excising a piece of the trachea. The incision will open further as you extend the neck over the rolled towel. • In adults, excise a small rounded segment of the trachea (Figure 16.21). The size of the resulting hole should conform to that of the tracheostomy tube.
Figure 16.16
Figure 16.17
Figure 16.18
Figure 16.19
Figure 16.20
Figure 16.21
5	Aspirate secretions from the trachea at this stage (Figure 16.22) and again after insertion of the tube.
Figure 16.22
6	Insert the tracheostomy tube set, remove the obturator and loosely stitch the skin with interrupted 2-0 thread (Figures 16.23, 16.24): • In children, remove the rolled towel from under the shoulders before stitching the skin; a linen tape can be passed behind the neck to join the wings of the tube and hold it in place (Figure 16.25).
Figure 16.23
Figure 16.24
Figure 16.25
7	When placing the tracheostomy tube in the trachea, ensure that it enters the lumen accurately and completely. If the patient has been intubated, ensure that the tracheostomy tube is below the endotracheal tube; if necessary, withdraw the endotracheal tube to make this possible. Assess and confirm the patency of the inserted tracheostomy tube using the bell attachment of a stethoscope. If there is a normal flow of air through the tube, a loud blast will be heard with each expiration. With incomplete obstruction, the noise will be softer and shorter, accompanied by a wheeze or whistle. If the tube has been placed pretracheally or if it is completely blocked with secretions, no sound will be heard. Remove and replace the tube if you have any doubts about its position or patency.

Aftercare

Aspirate secretions from the tracheobronchial tree regularly, using a sterile catheter passed down through the tracheostomy tube. Avoid irritating the bronchi, which could stimulate coughing.

The air around the patient should be kept warm and humid by means of a humidifier. When necessary, instil small amounts of sterile physiological saline into the bronchi to soften the mucus.

Change the inner tracheostomy tube at regular intervals. If the outer tube becomes dislodged, reinsert it immediately and check its position both by clinical examination and chest radiography. Always have a spare tube available.

Refer the patient for further treatment, if necessary.

Complications

Complications include:

Stenosis of the trachea is a possible late complication.

FASCIOTOMY

See Unit 18: Orthopaedic Trauma (18.8: Complications).

BURR HOLES

See Unit 17: Orthopaedic Techniques (17.6: Cranial Burr Holes).