Trauma Chest Drains
Grant Christey
Outline
Trauma Chest Drains
Problems and Solutions
Grant Christey
Today
• The Problem
• Complications
• Anatomy
• Indications
• Technique
• Drain removal
• Summary
So What’s the Problem?
• Many subcritical errors are unrecorded.
• Knowledge of chest drain use and technical skill required are generally underrated and poorly understood
• We have an opportunity to improve
Anatomy
Complications
• Overall Complication Rates
– 30% Bailey. J Acc E Med 2000 Mar;17(2):111-4 (n=57)
– 25% Deneuville. E J Card Surg. 2002;22(5):673 (n=134)
• Drain malposition
– Curtin et al. Am J Roent. Vol 163, 1339-1342 (n=66)
• Intrafissural/pleural 38%
– Baldt et al. Radiol 1996 Jan;198(1):19 (CT Study: n=77)
• Tube malposition overall 26%
• Persistent htx/ptx 20.7%
• Intrafissural 11.7%
• Intrapleural 6.5%
More Complications
• Lung injury 7%
– Deneuville. E J Card Surg. 2002;22(5):673-8 (n=134)
• Empyema 2.4%
– Millikan et al. Am J Surg. 1980 Dec;140(6):122
• Subclavian vessel injury
• Mediastinum
• Diaphragm
• Bronchi
• Liver
• Spleen, etc
Risk Factors for Morbidity
Deneuville M. E J Card Surg. 2002;22(5):673 (n=134)
– Polytrauma RR=2.7
– Assisted ventilation RR = 2.7
– ED physician insertion RR=8.7
– Transfer from other hospital (38% compl. rate)
The key issues in success are level of training, experience and technical skill.
Potential Hilar Injury
Hilar injury
Where’s that drain going?
Anterior drain, posterior fluid
Who gets a chest drain?
• Therapeutic
– Haemothorax
– >20% pneumothorax
• Prophylactic
– patient to undergo GA, IPPV, or transport
• Diagnostic
– in unstable multi-trauma victim
• Monitoring
– Post-thoracotomy
Insertion
• at least 32 Fr for all trauma, or as big as possible
• No trocars
• Sterile technique
• It is vital to understand the anatomy and visualise the direction of the drain before starting the procedure.
• Ensure local anaesthesia and be gentle.
Safe Zone
anterior border of the latissimus dorsi
lateral border of the pectoralis major muscle
a line horizontal to the nipple
Placement
• Mark exact incision point: mid-axillary line at superior edge of 5th rib. Inject LA deep.
• 3cm incision parallel to rib through skin and fat.
• Straight clamp obliquely down a single track parallel to rib, 45° to skin.
Placement
• Perforate pleura with fingertip and record whoosh of air.
• Push tip of drain into thorax with a fingertip.
• Tip goes posteriorly and toward the apex.
• Connect to underwater sealed drain.
All trauma chest drains get continuous suction at
-20 mmHg at all times
Drain removal
• Remove when:
– <200 mls/day
– Drain not bubbling
– Clinically improving
– Not for further IPPV
Removal tips
• Mid inspiration is easiest
• One smooth movement, then occlusive dressing on.
• No clamps
• CXR within 1 hour of removal, not before.
[Adrales et al. J Trauma 2002 Feb;52(2):210-4]
• Tell the patient what you are doing and instruct on signs of recurrence.
Dilemmas
• Prophylactic Antibiotics? = Yes
• Drain removal on inspiration or expiration? = No clear winner. Mid-inspiration is easiest.
• Can anyone do it? = Yes, but complications are much rarer with experience and training
Summary
• Chest drain placement demands clear clinical judgement and technical precision
• Understand the anatomy
• Rehearse your technique
• If the drain isn’t swinging, it’s not working.
• Do not underestimate the cost of technical failure to the patient
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Ministry
of Health
