Chest drain insertion

Aim

To describe the indications and procedures for chest drain insertion in adult trauma patients as well as post procedure monitoring and removal.

Background and Safety

Chest trauma is common in major trauma, both penetrating and blunt. In particular motor vehicle collisions are associated with significant amounts of chest trauma, and the commonest cause in our setting. 25 % of all trauma deaths are due to chest trauma. Thus the chest must be quickly and accurately assessed allowing treatment to occur in a timely fashion. Serious chest injuries account for approximately 4000 deaths in the UK each year. Many of these patients will require chest drain insertion.

Incorrect placement of a chest drain can lead to significant morbidity and even mortality

They are 4 key British Thoracic Society recommendations.

1. All personnel undertaking the procedure should have been suitably trained in theory, simulated practice and should be supervised until considered competent
2. Pleural procedures should not take place out of hours unless it is an emergency
3. Pleural procedures should take place in a clean environment with full aseptic technique
4. Chest drain insertion should be delayed where possible in ant coagulated patients until the INR is < 1.5 

Indications for Chest Drain In Trauma

• Pneumothorax: following decompression of tension
• Haemo-pneumothorax
• Post surgery

Written consent should be obtained in all cases except in an emergency in which verbal consent should be sought where possible.

Complications that should be covered are

• Pain
• Intrapleural infection
  • Visceral injury
• Blockage

The insertion of chest drains is a painful procedure despite the use of local anaesthesia. Analgesia should be used in the non-anaesthetised patient and sedation considered where appropriate.

1st Line – intravenous Morphine
2nd Line – intravenous Ketamine

Positioning
The semi erect position is optimal for insertion of chest drains. In blunt trauma and unwell patients this may not be possible. In this situation the patient should remain supine and the arm lifted superiorly by an assistant.

Anatomy
Insertion should be in the triangle of safety, bordered anteriorly by the lateral edge of latissimus dorsi, the lateral border of pectoralis major and superior to the horizontal level of the fifth intercostal space.

Insertion

1. Confirm patient’s identity and review imaging/clinical signs
2. Use aseptic technique
3. Lidocaine 1% should be instilled paying particular attention to skin, periosteum and pleura
4. Make an incision (larger than drain and able to accommodate a finger) parallel to and above the rib
5.  Blunt dissection without undue force parting the intercostal muscles down to the pleural space
6. Finger the tract ensuring it is connected to the hemithorax
7. Insert the drain through the tract and suture in place using a 0 or 1-0 silk suture
8. Tape in place using the omental method as in figure 2
9. The drain should be attached to a valved passive closed drainage device and confirmed with swinging and bubbling 

• Administer 1.2g Co-Amoxiclav ideally before insertion and continue for 24 hours for all patients requiring a chest drain
• Consider tetanus status for all patients

• Record all plural procedures on TRAK system (Please refer to Pleural Procedures Documentation)
• Use the chest drain chart to record chest drain observations. (Please refer to Chest Drain Chart)