Emergency insertion of chest drains

Tension within the pleural space may compromise venous return, cardiac output or ventilation. In the emergency situation with an obtunded patient the aim is to release tension using the quickest and safest method with which the operator is familiar.

  1. Inserting a needle and aspirating is one method for diagnosis and treatment of tension.

  2. A large bore needle or Venflon may be used.

  3. A spring-loaded, sheathed ‘Verres’ needle (Reference: Ethicon Endopath Ultra Verres needle UV150) provides an added safety mechanism for this purpose.

  4. If fluid or air are encountered a drain should then be inserted.

If a patient is to be ventilated with positive pressure following needle aspiration, whether fluid, air or nothing was encountered, a chest drain should be inserted.

The site of insertion will be dictated by the position of the patient. The axilla is recommended but the second intercostal space in the mid-clavicular line is a suitable alternative in the supine patient.

The method of insertion is generally along the lines described above for elective insertion though sedation and monitoring may not be possible.

It is important to try to maintain sterility though attempts to do so should not compromise life-saving procedures.

It may be wise not to use a trocar in the emergency situation as the position of the drain tip is not as important.

Once the emergency has past therapeutic antero-apical and postero-basal drains should be inserted and positioned to properly drain the pleural cavity. One of the commonest reasons for referral to Thoracic surgeons is inadequate drainage of the pleura with subsequent clotted haemothorax or empyema.