Ep 85 - Top tips for chest drains.

Title: Mastering Chest Drains: Essential Tips and Techniques for Emergency Medicine

In this comprehensive guide, Simon Carley and Rick Bodey from St Emlyns explore the essential aspects of chest drains, also known as intercostal drains or chest tubes, focusing on their importance, optimal techniques, and common pitfalls in emergency medicine.

Importance of Chest Drains

Chest drains are critical for managing conditions like pneumothorax, hemothorax, and pleural effusion by removing air, blood, or fluid from the pleural cavity. Despite not being a daily procedure in the UK, proficiency in chest drain insertion is crucial due to the potential for severe complications, including organ damage and infection. Proper training and careful execution are necessary, especially as new technologies and medical practices evolve.

Choosing the Right Size

Traditionally, large-bore drains (32-36 French) were used for pneumothoraces to prevent blockage by clots. However, recent evidence supports the use of smaller drains (28-32 French), even for trauma patients. Smaller drains are less invasive, cause less discomfort, and are equally effective. The move towards smaller drains aligns with a trend in medicine favoring minimally invasive procedures, which reduce patient risk and enhance comfort.

Management of Occult Pneumothoraces

Advances in imaging, like CT scans and ultrasound, have increased the detection of occult pneumothoraces, which are often asymptomatic and not visible on chest x-rays. Traditional guidelines recommended chest drains for all traumatic pneumothoraces, but recent research suggests conservative management may be appropriate in many cases. A systematic review found no significant difference in outcomes between patients with occult pneumothoraces managed conservatively and those who received chest drains. This highlights the importance of assessing each patient's condition, monitoring closely, and only intervening when necessary, particularly in stable, asymptomatic patients.

Optimizing Analgesia

Pain management during chest drain insertion is vital. Traditional local anesthesia methods are often insufficient, especially in trauma settings. Ketamine has emerged as an effective option, providing both analgesia and sedation without significant respiratory depression. Administered in small, incremental doses, ketamine helps manage pain and anxiety, making the procedure more tolerable. Additional analgesics, like fentanyl and midazolam, can complement ketamine, offering a multimodal approach to pain management.

Intra-Pleural Analgesia

Injecting local anesthetics, such as bupivacaine, into the pleural cavity can further enhance patient comfort, particularly as the lung re-expands and contacts the parietal pleura. This method is supported by randomized controlled trials and can significantly reduce pain in the first few hours post-insertion, aiding in better respiratory function and reducing the risk of complications like pneumonia.

Securing the Drain

Properly securing the chest drain is crucial to prevent accidental dislodgement, especially during patient transport or imaging. Techniques like Neil Bandari's "Jo'burg knot" offer reliable methods for securing drains, though simpler techniques may suffice for less frequent practitioners. Transparent dressings are recommended to allow monitoring of the insertion site and ensure the drain remains securely anchored.

The Role of Ultrasound

Ultrasound is an invaluable tool for accurately placing chest drains, particularly in cases of pleural effusion or complex pleural anatomy. It aids in identifying the best insertion site, reducing the risk of complications, and confirming the resolution of pneumothorax. Ultrasound is especially useful in patients with obesity or chronic lung conditions, where traditional landmarks may not be reliable.

Aspiration of Pneumothoraces

For primary spontaneous pneumothoraces, aspiration may be a viable alternative to chest drain insertion, particularly when specific criteria are met. This less invasive approach can be performed with a standard IV cannula or a small Seldinger technique, which also provides a pathway for chest drain insertion if necessary. This method is beneficial in outpatient settings, allowing for quick resolution without hospitalization.

Conclusion

The management of chest drains is a dynamic field, continually evolving with new research and technology. Emergency medicine practitioners must stay informed and adapt to evidence-based practices, including the use of smaller chest drains, conservative management of occult pneumothoraces, optimized analgesia, and the application of ultrasound. The goal is to provide safe, effective, and patient-centered care, minimizing unnecessary interventions.

At St Emlyns, we strive to share knowledge and best practices to enhance patient care. We invite our readers to contribute their insights and experiences, fostering a collaborative approach to improving clinical skills and outcomes in emergency medicine.