Review Note
Last Update: 03/02/2025 09:52 AM
Current Deck: ACG Part 2::Thoracic SSU
New Card (Unpublished)Currently Published Content
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Commit #292855
SS_TS 1.24 Discuss the management of chest drains and pleural drainage systems for thoracic trauma
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Commit #292855Indications :
- Drainage of air or fluid from intrapleural space.
- Can be use for pleural lavage rewarming in hypothermia.
METHOD OF INSERTION AND/OR USE
Anatomy
- landmarks = “triangle of safety”: anterior to mid axillary line, posterior to pectoral groove, above 5th intercostal space (ideally above 4th in pregnant patients)
- layers that must be breached (superficial to deep) = skin, subcutaneous tissue, intercostal muscles, parietal pleura
- awareness of the intercostal bundle sitting on the inferior aspect of the ribs
Equipment
- sterile clothing (gloves, gown, hat, mask, facial shield)
- chlorhexidine in 80% alcohol
- sterile drapes
- lignocaine 1%
- 22G long needle
- scalpel
- curved forceps
- chest drain (>24 French for blood)
- suture material
- underwater seal drain
- dressing
Technique
- explain procedure, obtain consent, sterile environment with equipment ready, skilled assistant, adequate analgesia, adequate resuscitation equipment and recovery facilities
- check coagulation profile, Hb, platelet number -> transfuse accordingly
- position patient (supine or 30 degrees head up) with arm abducted & elbow flexed
- sterile preparation of area
- identify rib spaces (4th to 7th) on left and anterior – mid axillary line
- skin infiltration with lignocaine 1%
- infiltrate down to parietal pleura (ensuring needle travels over the top of the chosen rib to protect neurovascular bundle)
- continuous aspiration of needle should reveal blood or air once in the pleural space
- make an incision following line of ribs with scalpel (1 to 2cm long)
- blunt dissection with finger or blunt forceps (this will ensure adherent lung is moved from insertion site)
- once parietal pleura breeched there should be a rush of blood
- dilate with finger
- load chest drain onto curved forceps (orientated towards the apex)
- use forceps to allow the clamped drain to follow the true lumen that has been created
- insert drain until an adequate length is within the pleural cavity (will depend of patient habitus)
- suture in place and dress with a sterile dressing
- connect to underwater seal drain (connections should be stable and easy to attach in a sterile manner)
POST INSERTION MANAGEMENT :
- CXR to confirm position - all holes should be inside the thoracic cavity, not kinked, ideally not abbuting lung apex or mediastinum.
- If drainage exceeds 1.5L, at risk of re-expansion oedema, after 1.5L drained. Recommended to clamp for 15mins before
- In haemothoraces >100ml/hr ongoing loss indicates possible arterial bleed and further investigation warranted.
- Normal pleural cavity has 4-20ml pleural fluid and turnover 0.2ml/kg/hr therefore if drain output under this it can be safely removed
- Usually removed if output <200ml/day
- If drain stops bubbling :
- Pneumothorax reexpanded
- Drain is kinked
- Suction disconnected
- If stops swinging :
- Lung re-expanded
- kinked/blocked
- Dislodged
Complication management :
- Subcut emphysema :
- 100% FiO2
- Resite drain
- Can do infraclavicular blowhole incisions or subcutaneous catheters.
https://derangedphysiology.com/main/required-reading/intensive-care-procedures/Chapter-261/thoracocentesis-chest-drain