Healthcare and Medicine Reference
In-Depth Information
Tension pneumothorax
Learning points
Smaller chest drains (10-14F) are usually effective and well
tolerated by patients.
Chest drains should be inserted within the 'triangle of safety.'
Never use excessive force when inserting a chest drain.
Never use the Trocar rod to insert the chest drain.
Never clamp a bubbling chest drain.
Handy hints/troubleshooting
Take time to explain the procedure thoroughly to the patient, and
talk them through it if appropriate.
Positioning the patient in a comfortable position is vital - they are
going to be there for some time.
If you are sedating the patient you should have two medical
practitioners, one doing the procedure and one responsible for
sedation and monitoring.
Use plenty of local anaesthetic - the maximum dose of 1%
lidocaine is approximately 20 mL for an average-sized adult.
Stitching in the chest drain securely is vital - they are notorious
for falling out. This is not only annoying, but can also be very
dangerous.
Remember to order (and look at) the post-procedure chest X-ray
and document the result.
Further reading
Antunes G, Neville E, Duffy J, Ali N. (2003) BTS Guidelines for the
Management of Malignant Pleural Effusions. Thorax 58 (Suppl II):
ii29-ii38.
Chapman S, Robinson G, Stradling J, West S. (2005) Oxford Handbook of
Respiratory Medicine . Oxford University Press, Oxford.
Davies CWH, Gleeson FV, Davies RJO. (2003) BTS Guidelines for the
Management of Pleural Infection. Thorax 58 (Suppl II): ii18-ii28.
Henry M, Arnold T, Harvey J. (2003) BTS Guidelines for the Management of
Spontaneous Pneumothorax. Thorax 58 (Suppl II): ii39-ii52.
Laws D, Neville E, Duffy J. (2003) BTS Guidelines for the Insertion of a Chest
Drain. Thorax 58 (Suppl II): ii53-ii59.
Maskell NA, Butland RJA. (2003) BTS Guidelines for the Investigation of a
Unilateral Pleural Effusion in Adults. Thorax 58 (suppl II): ii8-ii17.
National Patient Safety Agency. (2008) Rapid Response Report: Risks of Chest
Drain Insertion . National Patient Safety Agency, London.
Figure 17.11 A tension pneumothorax: complete collapse of the right lung
can be seen with the mediastinum forced over to the patient's left.
Box 17.3 Management of a tension pneumothorax
A tension pneumothorax (Figure 17.11) is a life-threatening
emergency that requires prompt diagnosis and treatment. It occurs
when gas accumulating in the pleural space cannot escape, most
commonly due to trauma (e.g. penetrating stab wound), or arising
from positive-pressure ventilation.
Features:
acute respiratory distress
absent breath sounds on affected side
Signs which may be harder to illicit include tracheal deviation away
from affected side, distension of neck veins and hyperresonance
over affected side.
If tension pneumothorax is present, a cannula of adequate length
should be promptly inserted into the second intercostal space in
the midclavicular line and left in place until a functioning intercostal
drain is inserted.
tachycardia and hypotension.
A tension pneumothorax is a clinical diagnosis and should
never be imaged (it needs urgent treatment).
 
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