The stem
A 25-year-old man was stabbed in the right chest. His chest X-ray shows a large right haemothorax. The registrar asks you about this equipment.
The equipment
The examiner’s questions
Question 1What is this, and what is it used for?Show the model answer
A chest drain (an intercostal drain) attached to an underwater seal bottle. It drains air, blood or fluid from the pleural space: pneumothorax, haemothorax, pleural effusion and empyema, and after chest surgery.
Question 2Where is it inserted?Show the model answer
In the safe triangle: the anterior border of latissimus dorsi, the lateral border of pectoralis major, a horizontal line at the level of the nipple (the fifth intercostal space), with its apex below the axilla. The tube passes just above the upper border of the rib below, to avoid the neurovascular bundle that runs under each rib.
Question 3How do you check that the drain is working?Show the model answer
The water in the tube swings with breathing, which shows it is in the pleural space and not blocked. Bubbling means air is still leaking. Record the volume drained. The bottle must stay below the level of the chest, and the tube end must stay under water.
Question 4What drainage would make you call the thoracic surgeon?Show the model answer
In trauma, 1,500 mL of blood immediately, or more than about 200 mL an hour for 2 to 4 hours, suggests the need for a thoracotomy. Complications of the drain include bleeding from an intercostal vessel, injury to lung, liver or spleen, infection, surgical emphysema and re-expansion pulmonary oedema.
After you answerThe teaching pointShow
Never clamp a drain that is bubbling: the air has nowhere to go and a tension pneumothorax can follow.
The drawings were made for this site. The patients are written for teaching and are not real.