What is the proper procedure for emergency chest drain insertion?

Emergency Chest Drain Insertion Procedure

The proper procedure for emergency chest drain insertion requires ultrasound guidance, insertion through the 'safe triangle' in the mid-axillary line between the 4th and 5th intercostal space, using small-bore drains with the Seldinger technique whenever possible to minimize patient discomfort while maintaining effectiveness. 1

Pre-Insertion Assessment and Preparation

1. Personnel and Setting:

   • Ensure procedure is performed by adequately trained personnel with a suitable assistant and trained nurse 2, 1
   • Manage patients on specialist wards by staff trained in chest drain management 2, 1

2. Pre-procedure Investigations:

   • Obtain chest radiograph to confirm diagnosis 2, 1
   • Mandatory ultrasound to confirm diagnosis and mark optimal insertion site 2, 1
   • Document patient position during marking to ensure consistency during insertion 2

3. Coagulation Assessment:

   • Routine coagulation studies only needed for patients with known risk factors 2, 1
   • Correct any coagulopathy or platelet defect before insertion when possible 2, 1

4. Anesthesia Considerations:

   • General anesthesia is preferred for children and non-cooperative patients 2
   • If using conscious sedation, it must be administered by personnel trained in sedation, airway management, and pediatric resuscitation with full monitoring equipment 2
   • Use local anesthesia even with general anesthesia for pain control 2

Insertion Technique

1. Patient Positioning:

   • For local anesthesia: Position patient slightly rotated with arm on affected side behind head to expose axillary area 1
   • Alternative positions: upright leaning over a table with pillow or lateral decubitus 1
   • For general anesthesia: Position flat on back, roll if marked site is posterior 1

2. Sterile Technique:

   • Use sterile gloves, gown, and sterile towels after effective skin cleansing 1

3. Drain Selection:

   • Use small-bore drains (8-12 FG) for most situations 2, 1
   • Small drains (including pigtail catheters) cause less discomfort with equal effectiveness 2

4. Insertion Site:

   • Insert at site marked by ultrasound 2, 1
   • Preferentially place in the 'safe triangle' in mid-axillary line 2, 1
   • The 'safe triangle' is bordered by:
     • Anteriorly: lateral edge of pectoralis major
     • Posteriorly: anterior border of latissimus dorsi
     • Inferiorly: line superior to horizontal level of nipple
     • Apex: below the axilla 1

5. Insertion Method:

   • Use Seldinger technique for small-bore drains 2, 1
   • Never use substantial force or a trocar to insert a drain 2, 1
   • Perform blunt dissection through chest wall 3

Post-Insertion Care

1. Immediate Post-Insertion:

   • Perform chest radiograph to confirm proper tube position 2, 1
   • Connect to unidirectional flow drainage system (underwater seal) 2, 1
   • Keep drainage system below patient's chest level at all times 2, 1
   • Secure drain with non-absorbable suture and appropriate dressings 1

2. Drain Management:

   • Never clamp a bubbling chest drain 2, 1
   • Immediately unclamp and seek medical advice if patient complains of breathlessness or chest pain 2
   • For initial large fluid volumes, clamp drain for 1 hour after removing 10 ml/kg 2
   • Check for obstruction by flushing if sudden cessation of fluid drainage occurs 2

3. Drain Removal:

   • Remove once clinical resolution is achieved 2, 1
   • Replace drain that cannot be unblocked if significant pleural fluid remains 2
   • Requires two practitioners when secured with mattress suture 4

Common Pitfalls and Complications

1. Complications occur in up to 25% of cases, ranging from drain misplacement to lethal iatrogenic injuries 5

2. Malposition Issues:

   • Lateral approach has higher risk of interlobal malposition (25%) compared to ventral approach (9.5%) 6
   • Clinically relevant malfunction requiring repositioning occurs in approximately 6% of malpositioned tubes 6

3. Prevention of Complications:

   • Use ultrasound to exclude vulnerable intercostal arteries 5
   • Avoid using trocars which increase risk of organ injury 2, 3
   • Ensure proper training and supervision 2
   • Follow the step-by-step ultrasound-guided technique to minimize complications 5

By following this structured approach to emergency chest drain insertion, clinicians can minimize complications while ensuring effective treatment of pleural conditions requiring drainage.