What is the proper procedure for emergency chest drain insertion?

Emergency Chest Drain Insertion Procedure

Emergency chest drain insertion should be performed using ultrasound guidance with the Seldinger technique in the 'safe triangle' by adequately trained personnel, using small-bore drains (8-12 FG) for most situations to minimize complications while ensuring effective treatment. 1

Pre-Procedure Considerations

• Ensure procedure is performed by adequately trained personnel with a suitable assistant and trained nurse
• Obtain chest radiograph and perform mandatory ultrasound to:
  • Confirm diagnosis
  • Mark optimal insertion site
  • Document patient position during marking
• Only obtain routine coagulation studies for patients with known risk factors
• Correct any coagulopathy or platelet defect before insertion when possible

Equipment and Patient Preparation

• Select appropriate drain size:
  • Small-bore drains (8-12 FG) for most situations (less discomfort with equal effectiveness)
  • Larger drains may be needed for specific indications like hemothorax
• Position patient appropriately (typically semi-recumbent at 45° with arm raised)
• Prepare sterile field and equipment
• Administer appropriate anesthesia:
  • Local anesthesia for cooperative adults
  • General anesthesia for children and non-cooperative patients
  • Always use local anesthesia even with general anesthesia for pain control
  • If using conscious sedation, ensure administration by trained personnel with full monitoring equipment

Insertion Technique

1. Use ultrasound to identify the optimal insertion site within the 'safe triangle':

   • Bordered anteriorly by lateral edge of pectoralis major
   • Posteriorly by anterior border of latissimus dorsi
   • Inferiorly by a line superior to horizontal level of nipple
   • Apex below the axilla

2. Use ultrasound to exclude vulnerable intercostal arteries

3. Perform the Seldinger technique at the marked site:

   • Administer local anesthetic to skin, subcutaneous tissue, periosteum, and pleura
   • Make a small incision at the marked site
   • Insert the needle with syringe attached, aspirating as you advance
   • Once air/fluid is aspirated, remove syringe and insert guidewire
   • Dilate the tract over the guidewire
   • Insert the drain over the guidewire
   • Remove the guidewire

4. Important safety notes:

   • Avoid using trocars as they increase risk of organ injury 1
   • During COVID-19, consider chest tube insertion as an aerosol-generating procedure and use appropriate PPE

Post-Insertion Care

• Obtain chest radiograph to confirm proper tube position
• Connect drain to unidirectional flow drainage system (underwater seal)
• Keep drainage system below patient's chest level
• Secure drain properly to prevent dislodgment
• Never clamp a bubbling chest drain
• If patient complains of breathlessness or chest pain, immediately unclamp drain and seek medical advice
• Manage patients on specialist wards by staff trained in chest drain management

Drain Removal

• Remove drain once clinical resolution is achieved
• Removal requires two practitioners 2:
  • One to remove the tube
  • Another to tie the mattress suture (if present) and secure the site
• Assess anticoagulation status before removal
• If drain cannot be unblocked and significant pleural fluid remains, replace it

Common Pitfalls and Complications

• Malposition occurs in approximately 20% of cases, with interlobal placement being more common with lateral approach than ventral approach 3

• Up to 25% of chest drain insertions may have complications 4

• Most common complications include:

  • Drain misplacement
  • Injury to intercostal vessels
  • Organ perforation
  • Infection or empyema

• Prevention strategies:

  • Always use ultrasound guidance to identify anatomy and exclude vulnerable vessels 4
  • Avoid using trocars
  • Ensure proper training and supervision
  • Use the 'safe triangle' for insertion
  • Follow the step-by-step technique carefully