Yes, analgesia should absolutely be provided for chest tube insertion in ATLS settings
Local anesthesia must be routinely administered during chest tube insertion, regardless of technique, to reduce pain and improve patient safety. 1
Evidence-Based Approach to Analgesia
For Chest Tube Insertion
The most recent critical care guidelines (2025) provide strong expert consensus that local anesthesia should be used routinely during chest tube insertion 1. This applies to all trauma settings, including ATLS protocols.
Specific analgesic strategies include:
- Local anesthetic infiltration of the insertion tract (skin, subcutaneous tissue, intercostal muscles, and parietal pleura) using lidocaine 1-10% (maximum dose 9 mg/kg lean body weight) 2
- Preemptive analgesia with IV opioids (morphine, fentanyl, or sufentanil) prior to the procedure 3
- Regional anesthesia techniques such as ultrasound-guided thoracic paravertebral block (TPVB) when time and expertise permit 4
Critical Safety Consideration
Pain control is not just about comfort—it's about preventing life-threatening complications. A 2024 case report documented pulseless electrical activity (PEA) requiring chest compressions due to vasovagal reflex during chest tube insertion in a young patient with adequate vital signs 5. This underscores that inadequate analgesia can trigger severe bradycardia and cardiac arrest, particularly in young patients with spontaneous pneumothorax.
Practical Implementation Algorithm
Step 1: Immediate preparation
- Administer IV opioid (fentanyl 0.5-1 mcg/kg or morphine equivalent) 2-5 minutes before procedure 2, 3
- Consider atropine pre-administration in young patients to prevent vasovagal response 5
Step 2: Local anesthesia
- Infiltrate insertion site with lidocaine from skin through parietal pleura
- Allow 5 minutes for onset 2
Step 3: Advanced techniques (if available)
- Ultrasound-guided TPVB provides superior hemithoracic analgesia across multiple dermatomes without sedation risks 4
- This is particularly valuable for awake, cooperative patients
Step 4: Avoid these pitfalls
- Do NOT rely on vital signs alone to assess pain—they are unreliable predictors 3
- Do NOT skip preemptive analgesia even in hemodynamically stable patients 5
- Do NOT adjust ventilator settings (PEEP/tidal volume) during insertion—this does not reduce complications and may worsen oxygenation 1
For Chest Tube Removal
Chest tube removal is often MORE painful than insertion and requires multimodal analgesia 1, 3, 1:
- Subcutaneous bupivacaine infiltration (superior to IV morphine alone, with pain scores of 9.5 vs 18.9 mm; p<0.001) 1
- Topical cold application 15-20 minutes before removal 1
- IV opioids plus relaxation techniques 3
The 2013 Critical Care Medicine guidelines provide a strong recommendation (Grade 1C) that preemptive analgesia and/or nonpharmacologic interventions be administered prior to chest tube removal 3.
Key Takeaway
In ATLS settings, the urgency of the situation does NOT justify omitting analgesia. Local anesthesia takes only minutes to administer and significantly reduces both pain and the risk of life-threatening vasovagal complications. The combination of local infiltration plus IV opioids represents the standard of care supported by the highest quality guidelines 1, 3, 1.