Notfall + Rettungsmedizin

, Volume 21, Issue 3, pp 212–224 | Cite as


A pictorial essay on approaches and potential pitfalls
  • N. Hammer
  • D. Häske
  • A. Höch
  • C. Babian
  • B. Hossfeld
  • P. Voigt
  • D. Winkler
  • M. Bernhard



Thoracic trauma with consecutive pneumothorax or haematothorax can be accompanied by progressive respiratory failure. If untreated, this poses the risk of developing 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.


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.


Chest tubes Hematothorax Needle decompression Respiratory failure Tension pneumothorax 


Bebilderte Anleitung zur Anlage und potenzielle Fehlerquellen



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.


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.


Hämatothorax Nadeldekompression Respiratorisches Versagen Spannungspneumothorax Thoraxdrainage 



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.

Compliance with ethical guidelines

Conflict of interest

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.


  1. 1.
    Abad C, Padron A (2002) Accidental perforation of the left ventricle with a chest draintube. Tex Heart Inst J 29:143PubMedPubMedCentralGoogle Scholar
  2. 2.
    Aho JM, Thiels CA, El Khatib MM et al (2016) Needle thoracostomy: clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg 80:272–277CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Arbeitsgemeinschaft Der Wissenschaftlichen Medizinischen Fachgesellschaften EV (2016) S3 – Leitlinie Polytrauma/Schwerverletzten-Behandlung. AWMF Register-Nr. 012/019:446Google Scholar
  4. 4.
    Bailey RC (2000) Complications of tube thoracostomy in trauma. J Accid Emerg Med 17:111–114CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Baldt MM, Bankier AA, Germann PS et al (1995) Complications after emergency tube thoracostomy: assessment with CT. Radiology 195:539–543CrossRefPubMedGoogle Scholar
  6. 6.
    Bergaminelli C, De Angelis P, Gauthier P et al (1999) Thoracic drainage in trauma emergencies. Minerva Chir 54:697–702PubMedGoogle Scholar
  7. 7.
    Bernhard M, Helm M, Mutzbauer T et al (2010) Invasive Notfalltechniken: Intraossäre Punktion, Notfallkoniotomie und Thoraxdrainage. Notfallmed Up2date 5:41–59CrossRefGoogle Scholar
  8. 8.
    Bernhard M, Helm M, Mutzbauer TS et al (2010) Invasive Notfalltechniken. Notf Rettungsmed 13:399–414CrossRefGoogle Scholar
  9. 9.
    Bowness J, Kilgour PM, Whiten S et al (2015) Guidelines for chest drain insertion may not prevent damage to abdominal viscera. Emerg Med J 32:620–625CrossRefPubMedGoogle Scholar
  10. 10.
    Broder JS, Fox JW, Milne J et al (2016) Heimlich valve orientation error leading to radiographic tension pneumothorax: analysis of an error and a call for education, device redesign and regulatory action. Emerg Med J 33:260–267CrossRefPubMedGoogle Scholar
  11. 11.
    Buschmann CT, Kleber C, Schulz T et al (2012) Notfallmedizin up2date. Rechtsmedizin 22:197–216CrossRefGoogle Scholar
  12. 12.
    Cameron EW, Mirvis SE, Shanmuganathan K et al (1997) Computed tomography of malpositioned thoracostomy drains: a pictorial essay. Clin Radiol 52:187–193CrossRefPubMedGoogle Scholar
  13. 13.
    Chan L, Reilly KM, Henderson C et al (1997) Complication rates of tube thoracostomy. Am J Emerg Med 15:368–370CrossRefPubMedGoogle Scholar
  14. 14.
    Chang SJ, Ross SW, Kiefer DJ et al (2014) Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax. J Trauma Acute Care Surg 76:1029–1034CrossRefPubMedGoogle Scholar
  15. 15.
    Covelli V, Cavallo P (2008) Unusual late complication of chest tube thoracostomy. Inj Extra 39:335–336CrossRefGoogle Scholar
  16. 16.
    Daly RC, Mucha P, Pairolero PC et al (1985) The risk of percutaneous chest tube thoracostomy for blunt thoracic trauma. Ann Emerg Med 14:865–870CrossRefPubMedGoogle Scholar
  17. 17.
    De Lesquen H, Avaro JP, Gust L et al (2015) Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg 20:399–408CrossRefPubMedGoogle Scholar
  18. 18.
    Etoch SW, Bar-Natan MF, Miller FB et al (1995) Tube thoracostomy. Factors related to complications. Arch Surg 130:521–526CrossRefPubMedGoogle Scholar
  19. 19.
    Fitzgerald M, Mackenzie CF, Marasco S et al (2008) Pleural decompression and drainage during trauma reception and resuscitation. Injury 39:9–20CrossRefPubMedGoogle Scholar
  20. 20.
    Gooding CA, Kerlan RK Jr., Brasch RC (1981) Partial aortic obstruction produced by a thoracostomy tube. J Pediatr 98:471–473CrossRefPubMedGoogle Scholar
  21. 21.
    Griffiths JR, Roberts N (2005) Do junior doctors know where to insert chest drains safely? Postgrad Med J 81:456–458CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Haron H, Rashid NA, Dimon MZ et al (2010) Chest tube injury to left ventricle: complication or negligence? Ann Thorac Surg 90:308–309CrossRefPubMedGoogle Scholar
  23. 23.
    Harris T, Masud S, Lamond A et al (2015) Traumatic cardiac arrest: a unique approach. Eur J Emerg Med 22:72–78CrossRefPubMedGoogle Scholar
  24. 24.
    Havelock T, Teoh R, Laws D et al (2010) Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax 65(Suppl 2):ii61–ii76CrossRefPubMedGoogle Scholar
  25. 25.
    Hecker M, Hegenscheid K, Volzke H et al (2016) Needle decompression of tension pneumothorax: population-based epidemiologic approach to adequate needle length in healthy volunteers in Northeast Germany. J Trauma Acute Care Surg 80:119–124CrossRefPubMedGoogle Scholar
  26. 26.
    Huber-Wagner S, Korner M, Ehrt A et al (2007) Emergency chest tube placement in trauma care – which approach is preferable? Resuscitation 72:226–233CrossRefPubMedGoogle Scholar
  27. 27.
    Husain LF, Hagopian L, Wayman D et al (2012) Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock 5:76–81CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Icoz G, Kara E, Ilkgul O et al (2003) Perforation of the stomach due to chest tube complication in a patient with iatrogenic diaphragmatic rupture. Acta Chir Belg 103:423–424CrossRefPubMedGoogle Scholar
  29. 29.
    Kaserer A, Stein P, Simmen HP et al (2016) Failure rate of prehospital chest decompression after severe thoracic trauma. Am J Emerg Med. doi: 10.1016/j.ajem.2016.11.057 PubMedGoogle Scholar
  30. 30.
    Kerger H, Blaettner T, Froehlich C et al (2007) Perforation of the left atrium by a chest tube in a patient with cardiomegaly: management of a rare, but life-threatening complication. Resuscitation 74:178–182CrossRefPubMedGoogle Scholar
  31. 31.
    Kleber C, Giesecke MT, Tsokos M et al (2013) Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg 37:1154–1161CrossRefPubMedGoogle Scholar
  32. 32.
    Kleber C, Giesecke MT, Lindner T et al (2014) Requirement for a structured algorithm in cardiac arrest following major trauma: epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation 85:405–410CrossRefPubMedGoogle Scholar
  33. 33.
    Kollef MH, Dothager DW (1991) Reversible cardiogenic shock due to chest tube compression of the right ventricle. Chest 99:976–980CrossRefPubMedGoogle Scholar
  34. 34.
    Kopec SE, Conlan AA, Irwin RS (1998) Perforation of the right ventricle: a complication of blind placement of a chest tube into the postpneumonectomy space. Chest 114:1213–1215CrossRefPubMedGoogle Scholar
  35. 35.
    Kuhajda I, Zarogoulidis K, Kougioumtzi I et al (2014) Tube thoracostomy; chest tube implantation and follow up. J Thorac Dis 6:S470–S479PubMedPubMedCentralGoogle Scholar
  36. 36.
    Maybauer MO, Geisser W, Wolff H et al (2012) Incidence and outcome of tube thoracostomy positioning in trauma patients. Prehosp Emerg Care 16:237–241CrossRefPubMedGoogle Scholar
  37. 37.
    Meisel S, Ram Z, Priel I et al (1990) Another complication of thoracostomy – perforation of the right atrium. Chest 98:772–773CrossRefPubMedGoogle Scholar
  38. 38.
    Menger R, Telford G, Kim P et al (2012) Complications following thoracic trauma managed with tube thoracostomy. Injury 43:46–50CrossRefPubMedGoogle Scholar
  39. 39.
    Miller KS, Sahn SA (1987) Chest tubes. Indications, technique, management and complications. Chest 91:258–264CrossRefPubMedGoogle Scholar
  40. 40.
    Millikan JS, Moore EE, Steiner E et al (1980) Complications of tube thoracostomy for acute trauma. Am J Surg 140:738–741CrossRefPubMedGoogle Scholar
  41. 41.
    Naemt (ed) (2016) Präklinisches Traumamanagement. Prehospital Trauma Life Support (PHTLS), Deutsche Bearbeitung durch PHTLS Deutschland und Schweiz. Urban & Fischer in Elsevier, MünchenGoogle Scholar
  42. 42.
    Schulz-Drost S, Matthes G, Ekkernkamp A (2015) Erstversorgung des Patienten mit schwerem Thoraxtrauma. Notf Rettungsmed 18:421–437CrossRefGoogle Scholar
  43. 43.
    Schulz-Drost S, Matthes G, Ekkernkamp A (2015) Thoraxtrauma. Notfallmed Up2date 10:17–32CrossRefGoogle Scholar
  44. 44.
    Sethuraman KN, Duong D, Mehta S et al (2011) Complications of tube thoracostomy placement in the emergency department. J Emerg Med 40:14–20CrossRefPubMedGoogle Scholar
  45. 45.
    Surgeons ACO (2012) ATLS manual. American College of Surgeons, ChicagoGoogle Scholar
  46. 46.
    Takanami I (2005) Pulmonary artery perforation by a tube thoracostomy. Interact Cardiovasc Thorac Surg 4:473–474CrossRefPubMedGoogle Scholar
  47. 47.
    Volpicelli G (2011) Sonographic diagnosis of pneumothorax. Intensive Care Med 37:224–232CrossRefPubMedGoogle Scholar
  48. 48.
    Waydhas C, Sauerland S (2007) Pre-hospital pleural decompression and chest tube placement after blunt trauma: a systematic review. Resuscitation 72:11–25CrossRefPubMedGoogle Scholar
  49. 49.
    Zardo P, Busk H, Kutschka I (2015) Chest tube management: state of the art. Curr Opin Anaesthesiol 28:45–49CrossRefPubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH 2017

Authors and Affiliations

  • N. Hammer
    • 1
    • 2
  • D. Häske
    • 3
  • A. Höch
    • 4
  • C. Babian
    • 5
  • B. Hossfeld
    • 6
  • P. Voigt
    • 7
  • D. Winkler
    • 8
  • M. Bernhard
    • 9
  1. 1.Department of AnatomyUniversity of OtagoDunedinNew Zealand
  2. 2.Institute of AnatomyUniversity of LeipzigLeipzigGermany
  3. 3.Faculty of MedicineEberhard Karls University TübingenTübingenGermany
  4. 4.Department of Orthopaedics, Trauma and Reconstructive SurgeryUniversity Clinic of LeipzigLeipzigGermany
  5. 5.Institute of Forensic MedicineUniversity of LeipzigLeipzigGermany
  6. 6.Department of Anesthesiology and Intensive Care Medicine, Section Emergency MedicineFederal Armed Forces Medical HospitalUlmGermany
  7. 7.Division of NeuroradiologyUniversity Clinic of LeipzigLeipzigGermany
  8. 8.Department of NeurosurgeryUniversity Clinic of LeipzigLeipzigGermany
  9. 9.Emergency DepartmentUniversity Hospital of LeipzigLeipzigGermany

Personalised recommendations