Tube thoracostomy through an existing stab wound after refusal of conventional chest tube placement: a case report

Abstract

Introduction and importance:

Tube thoracostomy is the standard treatment for traumatic hemothorax requiring pleural drainage and is usually performed through the safe triangle. Rarely, management becomes challenging when a patient refuses the conventional insertion site. We report an unusual case of tube thoracostomy performed through an existing stab wound after the patient refused a separate chest tube incision.

Case presentation:

An 18-year-old, previously healthy male presented 6 hours after a right posterior lower chest stab injury. Chest radiography showed a moderate right-sided hemothorax. Tube thoracostomy was indicated because of reduced air entry and pleural fluid collection. The patient and his father declined the conventional insertion site after a discussion of risks and available options. After wound reassessment, confirmation of pleural communication, and informed consent, a 28-Fr chest tube was inserted through the existing stab wound under digital guidance. Approximately 300 mL of blood was drained immediately, with clinical improvement and no complications. The patient remained stable. Computed tomography imaging, which had initially been declined, was performed before discharge and demonstrated an AAST grade III posterior right hepatic laceration without active bleeding. The liver injury was managed non-operatively.

Clinical discussion:

The safe triangle remains the standard approach for tube thoracostomy. This case highlights the importance of careful assessment, patient autonomy, informed consent, and close observation when an unusual clinical situation requires individualized management.

Conclusion:

Tube thoracostomy through an existing stab wound should not replace the conventional technique. This single case does not establish the safety, efficacy, or reproducibility of this approach. However, in exceptional circumstances, it may be considered with caution, while maintaining patient safety and adhering to established surgical principles.

Introduction

Chest trauma is a common cause of injury worldwide and contributes substantially to trauma-related morbidity and mortality^[1^].

Hemothorax is a common consequence of penetrating chest injury, and tube thoracostomy remains the standard treatment when pleural drainage is required^[1,2^]. The conventional technique involves insertion through the safe triangle, providing reliable access to the pleural cavity while minimizing injury to surrounding structures^[3^].

HIGHLIGHTS

• Tube thoracostomy remains the standard treatment for traumatic hemothorax requiring pleural drainage.

• This case describes an uncommon situation in which a patient declined the conventional chest tube insertion site.

• The existing stab wound was used only after careful reassessment, confirmation of pleural communication, and informed consent.

• The case emphasizes that respect for patient autonomy should be balanced with safe surgical decision-making.

• Any deviation from standard practice should be considered only for carefully selected patients, with close clinical monitoring.

Although tube thoracostomy is routine in trauma care, complications include tube malposition, bleeding, infection, and injury to adjacent organs^[4^]. Safe placement, therefore, depends on appropriate assessment, knowledge of thoracic anatomy, and careful technique^[3,4^]. Current trauma guidance provides recommendations for indications and technical principles, but limited guidance exists for the unusual situation in which a patient with decision-making capacity refuses the conventional insertion site despite a clear indication for drainage^[1,3^].

In such circumstances, clinicians must balance respect for patient autonomy with the duty to provide safe and effective treatment. This is particularly relevant in lower posterior chest injuries, where diaphragmatic and intra-abdominal injuries may coexist, and contamination and anatomical uncertainty may increase procedural risk^[1,3^].

We present an 18-year-old male with traumatic hemothorax managed by a tube thoracostomy through an existing right posterior stab wound after refusal of a separate, conventional chest tube incision. The decision followed reassessment of the wound, confirmation of pleural communication, discussion of alternatives and risks, and informed consent. This report does not propose an alternative standard technique but describes an exceptional, patient-specific situation requiring individualized decision-making. The manuscript was prepared according to the SCARE 2025 guidelines^[5^].

Case presentation

Patient information

An 18-year-old previously healthy male presented 6 hours after sustaining a penetrating knife injury to the right posterior lower chest. The entry wound was at the right 11th intercostal space, approximately 1.5 cm lateral to the midline (Fig. 1A). He reported right-sided chest discomfort and pain. He had no significant medical or surgical history and no known drug allergies.

Figure 1.

(A) The arrow indicates the posterior chest stab wound at presentation. (B) The arrow indicates the right-sided hemothorax on the initial chest radiograph. The image quality was limited by technical factors. (C) Day-3 post-procedural anteroposterior chest radiograph showing significant interval improvement of the right-sided hemothorax, with good right-lung re-expansion. The chest tube is not clearly visualized on this radiograph.

Clinical findings

On arrival, he was hemodynamically stable. Primary trauma assessment according to ATLS principles demonstrated a patent airway, spontaneous breathing, oxygen saturation of 98% on room air, no active external hemorrhage, and a Glasgow Coma Scale score of 15/15. Respiratory examination revealed reduced air entry over the right hemithorax. Abdominal examination showed mild epigastric tenderness without guarding, rigidity, distension, or peritonism.

A chest radiograph obtained at a peripheral healthcare facility demonstrated a moderate right-sided hemothorax (Fig. 1B). There was no pneumothorax, mediastinal shift, free subdiaphragmatic air, or radiographic evidence of a diaphragmatic hernia. Focused abdominal ultrasonography showed no intraperitoneal free fluid. Both kidneys appeared normal, but an ill-defined area of altered echogenicity in the posterior right hepatic lobe raised suspicion of liver injury.

Because of the low posterior wound, associated thoracoabdominal injuries were considered.

Diagnostic assessment and initial management decision

Contrast-enhanced computed tomography (CT) of the chest and abdomen was recommended to evaluate possible thoracoabdominal injury. The patient demonstrated decision-making capacity. He and his father were counseled regarding the diagnostic value of CT, possible missed injuries, and the consequences of delayed diagnosis. They initially declined CT, preferring close observation, but agreed to imaging if his condition worsened or further evaluation became necessary.

His admission hemoglobin was 12.5 g/dL. Because of the moderate hemothorax and reduced breath sounds, a tube thoracostomy was indicated. The standard approach, through a separate incision in the safe triangle, was explained, including the potential consequences of not draining the hemothorax, such as retained hemothorax, empyema, respiratory compromise, and the possible need for emergency intervention. The patient and his father declined an additional chest wall incision and requested that the existing stab wound be used if technically appropriate.

Procedure

Written informed consent was obtained for reassessment of the wound and, if feasible, a tube thoracostomy through the existing tract. The patient was positioned in the left lateral decubitus position, and the operative field was prepared and draped under aseptic conditions.

After local anesthesia was administered, the stab wound was carefully reassessed and irrigated with normal saline. Intermittent air leakage synchronous with respiration suggested communication with the pleural cavity. Gentle digital assessment confirmed pleural communication. The accessible tract was directed anteriorly and superiorly, and no resistance or intervening palpable structure was identified. The tract was gently widened with a finger to accommodate the 28-Fr chest tube. No formal surgical debridement was performed. Therefore, the existing tract was considered accessible for tube placement.

After further discussion of the risks of contamination, malposition, bleeding, injury to adjacent structures, and inadequate drainage, the patient accepted the procedure. A 28-Fr chest tube was carefully advanced through the existing wound into the pleural cavity under digital guidance and directed gently anteriorly and superiorly. No forceful advancement was used. The tube was connected to an underwater-seal drainage system. Approximately 300 mL of blood drained immediately, with improvement in chest discomfort. No immediate procedure-related complications occurred.

Postoperative course and further evaluation

Because CT had initially been declined and associated diaphragmatic or intra-abdominal injury remained possible, the patient was admitted for close observation. He received intravenous fluids, analgesia, and broad-spectrum intravenous antibiotics, and serial abdominal examinations remained reassuring, without increased tenderness, peritonism, or distension. Serial hemoglobin measurements remained stable at 12.5 g/dL, and no blood transfusion was required.

Pleural drainage progressively decreased, with a total chest tube output of approximately 500 mL. Intravenous antibiotics were continued for 7 days because of concern about the contaminated penetrating wound and the use of the existing wound for chest tube placement. This duration reflected case-specific clinical judgment and should not be considered standard for routine tube thoracostomy^[6^].

Serial chest radiographs showed satisfactory lung re-expansion without a persistent air leak or retained hemothorax. On day 3, a postprocedural anteroposterior chest radiograph demonstrated significant improvement in the right-sided hemothorax and good right-lung re-expansion; the chest tube was not clearly visualized on this radiograph (Fig. 1C). The chest tube was removed on hospital day 7 after adequate lung expansion and minimal drainage. A post-removal chest radiograph on hospital day 8 showed complete lung expansion without residual pleural collection (Fig. 2).

Figure 2.

Follow-up chest radiograph obtained 8 days after injury, showing complete lung re-expansion, no residual pleural collection, and no evidence of diaphragmatic herniation.

Before discharge, the patient and his father requested CT imaging that had initially been declined. CT of the chest and abdomen demonstrated an AAST grade III laceration of the posterior right hepatic lobe and a right L1 transverse-process fracture, without active contrast extravasation, diaphragmatic injury, hollow viscus injury, or intra-abdominal hemorrhage. The liver injury was managed non-operatively. He was discharged on hospital day 8 in good condition with advice to avoid strenuous activity for 6 weeks.

Follow-up

At 3 weeks, the posterior chest wound had healed well (Fig. 3), and the patient remained clinically well. At 3 months, he remained asymptomatic.

Figure 3.

Healed posterior chest wound at a 3-week follow-up after tube thoracostomy through the existing stab wound.

Case presentation timeline

Six hours after sustaining a right posterior chest stab injury, an 18-year-old male presented with a moderate right hemothorax. CT imaging was recommended but was initially declined, despite counseling about the risk of missed thoracoabdominal injuries. After he refused a separate conventional chest tube incision, the existing wound was reassessed, pleural communication was confirmed, and tube thoracostomy was performed through the stab wound after informed consent. The patient was monitored with serial examinations, hemoglobin measurements, and chest radiographs. The chest tube was removed on day 7. CT on day 8 showed an AAST grade III liver laceration without active bleeding, which was managed conservatively. At 3-month follow-up, he remained asymptomatic.

Discussion

Under normal circumstances, insertion through the safe triangle is preferred because it provides reliable pleural access while reducing the risk of injury to surrounding structures^[3^]. In this patient, the indication for drainage was clear, but the patient declined a separate incision at the conventional site.

Tube thoracostomy can cause malposition, bleeding, infection, and injury to adjacent structures^[4^]. These risks are particularly relevant when an existing stab tract is considered. Additional concerns include contamination, inadequate drainage or a retained hemothorax, and injury to intercostal, thoracic, diaphragmatic, or intra-abdominal structures. An existing wound should therefore not be assumed to provide a safe tube trajectory simply because it communicates with the chest.

In our patient, the existing wound was used only after careful reassessment. The wound was irrigated with normal saline, pleural communication was confirmed digitally, and the tract was gently widened with a finger to accommodate the tube. No formal surgical debridement was performed. No resistance or palpable intervening structure was identified. The tube was advanced gently under digital guidance rather than by blind, forceful insertion. These measures reduced but did not eliminate the inherent risks. The standard safe-triangle approach remains preferable whenever acceptable to the patient.

The literature on tube thoracostomy primarily addresses standard insertion techniques and the prevention of complications. Reports specifically describing chest tube placement through an existing penetrating wound following refusal of a conventional incision are limited^[4,7^]. Lewis and Georgoff discussed individualized minimally invasive strategies in selected thoracic trauma patients, emphasizing that deviations from established approaches should remain guided by patient condition and safety considerations^[7^]. The present case differs because the unusual access route was driven principally by informed refusal of a separate incision. Therefore, this experience should not be interpreted as evidence supporting the routine use of existing stab wounds for tube thoracostomy.

Patient autonomy was central to the management decision. The patient had decision-making capacity and was counseled regarding the recommended conventional approach, the risks of untreated hemothorax, the option of using the existing wound, and the potential complications of the latter. His initial refusal of CT was also discussed in terms of possible missed thoracoabdominal injury and delayed diagnosis. Documentation of capacity, counseling, and the patient’s preference supported shared decision-making^[8,9^].

The delayed CT illustrates the difficulty of managing lower posterior penetrating injuries. The wound location and ultrasound finding raised concern for hepatic and diaphragmatic injury. Although CT was initially declined, the patient remained hemodynamically stable, had reassuring serial abdominal examinations, and maintained stable hemoglobin without transfusion. These findings supported observation but did not exclude occult injury. CT was subsequently obtained at the patient’s request before discharge and identified a grade III hepatic laceration without active bleeding. Non-operative management was appropriate, given hemodynamic stability and the absence of other indications for operative intervention^[10^]. Delayed imaging should not be considered equivalent to timely CT when imaging is accepted.

Antibiotic use also requires cautious interpretation. Antibiotic prophylaxis for tube thoracostomy in trauma has been studied to reduce infectious complications, but recommendations do not establish that 7 days of intravenous antibiotics are necessary for every uncomplicated tube thoracostomy^[6^]. In this case, the prolonged course reflected concern regarding the contaminated penetrating injury and the use of an existing traumatic tract.

The favorable outcome cannot establish procedural safety. It may have reflected appropriate selection, confirmation of pleural communication, careful insertion, and close observation. Follow-up imaging demonstrated lung re-expansion and resolution of the hemothorax, with no immediate procedure-related complications. Nevertheless, one successful case cannot establish that the approach is safe, effective, or reproducible.

Limitations

This report describes a single patient and therefore cannot establish the safety, efficacy, reproducibility, or general applicability of tube thoracostomy through an existing stab wound. The approach was used only because the patient declined the conventional chest tube insertion site and should remain reserved for highly selected circumstances.

CT imaging was not performed initially because the patient and his father declined it, despite counseling on its diagnostic importance and the possibility of missed injuries. Although serial examinations and stable hemoglobin allowed for close observation, delayed CT carries a risk of missed injuries. Further reports are needed before conclusions can be drawn regarding the role, safety, or reproducibility of this approach.

Conclusion

Tube thoracostomy through an existing stab wound should not replace the standard safe-triangle approach. In exceptional circumstances in which a competent patient refuses conventional chest tube placement, use of an existing wound may be considered only after careful reassessment, confirmation of pleural communication, discussion of risks and alternatives, informed consent, and close monitoring. This single case cannot establish the safety, efficacy, or reproducibility of the technique. The case primarily highlights patient autonomy, individualized decision-making, and adherence to established surgical principles when management must be adapted to an unusual clinical circumstance.

Ethical approval

Ethical approval was not required for this single case report according to institutional guidelines.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying clinical images.

Sources of funding

No funding was received for this study.

Author contributions

Z.M.D.S.: Conceptualization, patient management, data interpretation, manuscript drafting, writing, and critical revision. B.A.W.: Data collection, manuscript review, and writing. Both authors approved the final manuscript.

Conflicts of interest disclosure

The authors declare no conflict of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Dr. Zubair Mohamed Dahir Sed.

Provenance and peer review

Not applicable.

Data availability statement

The data supporting this case report are available from the corresponding author upon reasonable request.