A Potentially Disastrous Life -Threatening Complication of Emergency Tube Thoracostomy in A Simple Case of Spontaneous Pneumothorax

Emergency tube thoracostomy carries risks of infective and technical complications. The aseptic technique is essential to prevent infections, while blunt dissection method can minimise the associated technical complications. Preparation and adherence to protocols as well as appropriate knowledge and skills, however, are of utmost importance to reduce risks of complications. Physicians must have adequate knowledge of anatomy and the procedure to ensure for accurate site tube placement without any complication. This case illustrates how a failure to appropriately use the instrument resulted in a displaced scalpel blade inside the thoracic cavity. It caused an unnecessary thoracotomy for blade retrieval. The mishap escalated a simple procedure to the potentially disastrous life-threatening event