It's #TraumaTuesday! This week we're going to start looking at the B of ABCDE, thoracic injuries! Let's check our vision and go for a quick drive around chest drains... (1/16)

First things first. There are 2 types of chest drains. Narrow bore, seldinger chest drains are inserted by the medics for pneumothorax, or to drain pleural effusions. Needle, wire, tube. Have a look (2/16):

In trauma, you're most likely draining blood (haemopneumothorax). Clotted blood would block a narrow bore seldinger drain - so you'll often see a large bore surgical chest drain technique, dissecting down to the pleura: (3/16)

Whichever technique you use, safety is key. The SAFE TRIANGLE is an area between Pectoralis Major, Lat Dorsi, the apex of the axilla, and the nipple line/5th intercostal space. It's higher in the armpit than you think! (4/16)

Outside of trauma, ultrasound is generally required when draining pleural effusions, for extra safety. You can also detect pneumothorax through the absence of lung sliding on USS (5/16): https://rebelem.com/ultrasound-detection-pneumothorax/

Ok so the drain's in. Breathe a sigh of relief and get that mandatory post-drain Chest x-ray! Now we'll look at how to assess a patient with a chest drain. (6/16)

First up, the easy stuff. There is more to the patient than a chest drain! Remember to look at the obs, inspect the drain site for infection, listen to the chest and feel for surgical emphysema (7/16)

You need to know three things:

1) Is it draining? If so - what and how much? This should be on a chest drain output chart...
2) Swinging?
3) Bubbling?

(8/16)

Swinging in a chest drain occurs with with intrathoracic pressure. Look at the tubing (not the drainage bottle) - is the level going up and down with inspiration? If not, it might be blocked or displaced. Look here, the swinging is at 00:30: (9/16)

Bubbling in a chest drain is easy - it's the air coming out of a pneumothorax through the UNDERWATER SEAL (the water in the bottle) of a chest drainage system. Drains for effusion should not be bubbling!! If they are, maybe there's an air leak... (10/16)

Sometimes chest drains are put on SUCTION, particularly if a pneumothorax is persistent. This is done at very low pressure... (11/16)

People get very stressed about something called Re-expansion pulmonary oedema - it can happen if you drain off more than 1L/hour , although it's pretty uncommon. It's common to CLAMP the drain (shut it off) at 1 hour, leave it a bit, then drain more later. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309092/

Importantly though, YOU SHOULD NEVER CLAMP A BUBBLING DRAIN. If it's a pneumothorax, you could precipitate a tension pneumothorax by clamping it off. (13/16)

Blocked drains can be flushed to try and clear debris. It's all about knowing how to use a 3 way tap (14/16):

Finally it's time to take the drain out. The key here is to get the patient to EXHALE or perform VALSALVA as you remove it. This way, you avoid removing it during inspiration, when a negative intrathoracic pressure would suck air into the chest. (15/16)

So there we have it! I hear Barnard Castle's got a 2 for 1 deal on trauma drains at the moment... Have a great week, and join us next week to continue the theme of chest trauma! Good @OSCEstop resource here: https://www.oscestop.com/chestdrainmx.pdf (16/16) #traumatuesday #FOAMEd #ATLS