Chest Drains Online Skills Pack

Table of Contents

1. Chest Drain Programme
2. Essential Pre-requisite Knowledge
3. Large bore chest drain insertion
4. Small-bore chest drain insertion
5. Pre-hospital chest drain insertion
   1. Pre-hospital considerations
   2. Clinical Signs of Tension Pneumothorax
   3. Questions to ask yourself before inserting a pre-hospital chest drain?
   4. Procedural Guidelines - Pre-hospital chest drain insertion
6. Chest drain management
7. Chest drain Removal
8. Risk Factors of Chest Drain Management
9. Theoretical Assessment - Chest Drains
10. Housekeeping
11. Appendices

Procedural Guidelines - Pre-hospital chest drain insertion

An equipment list is available at Appendix H and a Procedural Checklist can be found at Appendix C. These will be of use to you during the simulated practice session.

Click here for Appendix H.

Click here for Appendix C

The procedure should be carried out in a well-lit environment with full resuscitation equipment. The patient should be monitored, receive oxygen and have an intravenous cannula inserted before the procedure. As well as the competent practitioner who will insert the drain there should be an assistant present who is trained in the care of chest drains. In a patient with a suspected Tension Pneumothorax needle decompression should ALWAYS be performed prior to chest drain insertion.

• Examine the patient and confirm clinical findings.

• Position patient adequately with the arm on the side on which the drain is to be inserted behind the head.

• Gather appropriate equipment

• Identify the 'SAFE TRIANGLE' and choose point of insertion above a rib to avoid the neurovascular bundle

• Infiltrate local anaesthetic (maximum 3mg/kg 20ml 1% Plain lignocaine in 70kg adult), initially by drawing up a skin bleb with an orange needle and then using a green needle to infiltrate through the soft tissues onto the rib and pleura aspirating as the needle is advanced

• Maintain asepsis as much as possible

• Clean hands with alcohol gel and don sterile gloves

• Open chest drain pack keeping contents sterile

• Clean the skin using antiseptic skin spray

• Make a horizontal incision where the drain is to be inserted. Ensure that this is big enough for the drain (approximately 2-3cm) and goes through all the layers of the skin only

• Using forceps (come with Portex(c) frontline kit) blunt dissect through the subcutaneous tissues (open and close forceps to separate rather than cut tissues. Make sure that you dissect down onto the upper border of the rib and open the pleura (you should feel a sudden give and sometimes a hiss of air or flow of blood)

• Insert a finger into the pleural cavity and sweep round to make sure that the lung is not adhered to the chest wall (CAUTION if the patient has rib fractures as these may puncture your glove)

• Estimate depth of insertion by looking at the markings on the drain and distance from apex of the lung to your incision. All the holes along the length of the drain need to be within the pleural space.

• Insert the drain through the hole in the pleura and into the cavity; aim the drain towards the apex

• DO NOT LET GO OF THE DRAIN until it is safely sutured in place

• Attach the end of the drain onto the closed drainage bag and tubing, make sure air is draining freely

• Insert a stay suture and a close (mattress) suture that can be used to close the wound when the drain is removed. Make sure you use a strong suture like 1.0 silk or it may snap. Ensure that your stay suture is tight and slightly indents the drain

• Secure the drain to the skin using some cut swabs and SLEEK to ensure additional drain security in pre-hospital environment

• Dispose of all waste and sharps appropriately

• Record procedure details, including any complications