In the Field
Chest tube is the definitive answer for an unresolved pneumothorax or hemothorax. Needle decompression buys you minutes. Finger thoracostomy buys you longer but the tract closes itself. A chest tube with a one-way valve or water seal stays patent indefinitely and removes ongoing air or blood from the pleural space. The procedure requires more training, equipment, and time than needle decompression, which is why it is concentrated at role 2 and above. TCCC-CMC and TCCC-CPP providers may place chest tubes per skill and authorization.
Common Mistake
Inserting the tube too anteriorly or too far down. The 5th intercostal space in the anterior to mid-axillary line is the standard site; lower sites risk diaphragm or abdominal injury, and more anterior sites at the level of the heart risk cardiac injury. The other mistake is failing to secure the tube adequately. A chest tube that pulls out of the pleural space during transport defeats its purpose.
Technical Detail
Standard adult chest tube size 28 to 36 French for trauma (smaller tubes risk clotting with hemothorax). Insertion landmark: 5th intercostal space in the anterior axillary line, between the lateral edge of the pectoralis major and mid-axillary line; corresponds to the safe triangle bounded by anterior border of latissimus dorsi, lateral border of pectoralis major, and a horizontal line at nipple level. Procedure: prep and drape, local anesthetic if conscious, incision 3 to 4 cm horizontal over the rib below the target ICS, blunt dissection through subcutaneous tissue and intercostal muscle to the pleural space riding just above the upper rib edge to avoid the neurovascular bundle, finger sweep to confirm position and assess for adhesions, insert tube to depth based on patient size (typically 8 to 12 cm in adults), connect to one-way valve (Heimlich valve for field use) or water seal drainage system, suture in place, occlusive dressing.
