Traumatic pneumothorax / haemothorax

ATLS teaching emphasises the need to insert a chest drain in all cases of traumatic pneumothorax
There are a small number of cases that do not require immediate drainage
- usually simple, small pneumothoraces where the patient is well, not due to be ventilated and circumstances allow very close monitoring over the next 24 hours
Never leave a traumatic pneumothorax undrained without first discussing the case with the ED Duty Doctor.

Indications for chest drain insertion include

All tension pneumothoraces and haemothoraces - after needle thoracocentesis
All pneumothoraces in patients requiring controlled ventilation
All patients with significant surgical emphysema due to chest injury
Patients who develop surgical emphysema in spite of the presence of a chest drain, i.e. they may need a second drain or changing of the first drain.

Explain what is happening and reassure the patient
It may be advisable to premedicate with atropine to prevent a vasovagal reaction
If the patient is very anxious give a small dose of intravenous midazolam.
Always double check the correct side of insertion from the chest radiograph just before intubation
4th, 5th or 6th intercostal space in the mid-axillary line
Patient supine with the head of the bed elevated 30º and the patient's arm behind the head
Mark the site of insertion with a ball-point or similar pen.
Sterile skin preparation and use of gloves are essential
Select a large drain
Remove trochar
Find the curved (Roberts) clamp for inserting the drain tube
Ensure that all the connections fit tightly and that the underwater bottle containing sterile water is ready.

After palpating the intercostal space, raise an intradermal bleb of local anaesthetic, and then infiltrate the deeper tissues down to the parietal pleura, particularly around the periosteum on the upper surface of the lower rib (remember that the neurovascular bundle is on the lower surface). At first use a blue, and then green, needle with at least 10-20 ml of either 0.5% bupivacaine plus adrenaline or 1% lignocaine. Aspirate intermittently, looking for air in the syringe to confirm that the pleural space has been entered.
3 - 4 cm skin (& subcutaneous tissue) incision.
Insert two horizontal sutures across the incision, leaving them loose for subsequent sealing of the wound on drain removal (complicated circular stitches are unnecessary)
Using blunt dissection with forceps, make a wide tract through the intercostal muscles down to and through the parietal pleura
Listen for the escape of air or blood
Insert your finger along the track and sweep to ensure that there is nothing adherent to the inside of the pleura.
With Roberts, insert the drain pointing towards the apex
Look for "fogging" of the chest tube with expiration or listen for air movement
Connect to the underwater drain
Secure it firmly with a strong suture (one loop through the skin and multiple ties in at least four places on the tube itself)
Key-hole dressing around the intercostal drain with sleek
Request a repeat chest X-ray
Prescribe adequate analgesia.

Content by Dr Íomhar O' Sullivan 23/06/2000. Reviewed by Dr ÍOS 20/02/2004, 20/02/2005, 17/05/2005, 04/01/2007. Next review 04/01/2008.