By so doing, one assures that the chest tube is in fact placed within the pleural space. Sites for insertion are usually the fifth intercostal space midaxillary line or the second intercostal space midclavicular line. A closed thoracostomy utilizing a trocar is a useful alternative to the above, although the size of the chest tube may be insufficient to allow adequate removal of blood and clot. A chest tube should not be inserted through the missile tract. The chest tube should be secured to the patient and connected to a flutter valve such as the Heimlich.
Third priority is assigned to the management of bleeding and shock.
Little can be done for the thoracic casualty in shock at this echelon other than to start an intravenous infusion of crystalloid fluid through two or more large-bore catheters. Given a tactical situation in which direct aeromedical evacuation from the battlefield to surgical treatment facilities is not possible, the fundamental contribution of the unit level to the medical care of the thoracic combat casualty will be to prepare the casualty for safe evacuation to a definitive care facility. From the practical standpoint, this means that casualties with penetrating missile wounds of the chest that are clearly not superficial should have chest tubes placed. Ancillary interventions must include the administration of a potent antimicrobal agent and relief of pain if indicated. The University of Iowa.