A possible cause of chest tube malposition

Tube thoracostomy is one of the essential skills for physicians. However, tube malposition is a common issue, and little is known about the reasons for malposition or the underlying mechanism. This report presents a case of tube malposition with an identifiable cause. A patient with traumatic cardiac arrest and severe chest injury was transported. Bilateral thoracostomy was performed because of tension pneumothorax, and 400 mL of blood was drained from the left tube. However, while securing the tube, it was pushed out by 3–4 cm before complete fixation. The tube was advanced back in further without retrying the tube placement. However, postmortem chest X-ray imaging revealed the malposition of the left tube. The only reason for malposition in this patient was the advancement of the pulled-out tube without replacement. To reduce the rate of tube malposition, it is necessary to reinsert the tube rather than advancing the pulled-out tube.