Question of the day... Chest tube insertion

Today I studied surface anatomy of the thorax. So many times I see my own chest in the mirror and don't think about what's going on underneath. But clinical question time.

Indications of a tube thoracostomy include:

1. Pneumothorax
• Open vs closed
• Simple vs tension
• The diagnosis of a tension pneumothorax is purely clinical and an immediate needle thoracocentesis should be performed in the midclavicular line in the 2nd intercostal space to relieve the tension before a definitive tube thoracostomy is performed 
2. Haemothorax
3. Haemopneumothorax
4. Hydrothorax
5. Chylothorax
6. Empyema
7. Pleural effusion
8. Patients with penentrating chest wall injury who are/about to be intubated
9. Those at risk of pneumothorax about to undergo air transport

Contraindications:

1. Need for emergent thoracotomy

Relative:

1. Coagulopathy
2. Pulmonary bullae - COPD
3. Adhesions - previous thoracic surgery
4. Loculated pleural effusions or empyema
5. Skin infection over chest tube insertion site

What are the borders of the triangle of safety when performing a tube thoracostomy?

• Medial - lateral border of the pectoralis major
• Inferior - 5th intercostal space, or above the 6th rib
• Lateral - mid axillary line
• Apex - below the axilla

Go above the rib because this means the intercostal neurovascular bundle runs in the subcostal groove and thus will not be injured.