DRAINING BLOOD OR AIR FROM THE CHEST

DIAGNOSTIC ASPIRATION

EQUIPMENT A 10 or 20 ml ’Luer–lok’ syringe and a 1.6 mm short bevel ’Luer–lok’ needle. A 5 ml syringe, a fine needle, a No.11 scalpel blade, and some local anaesthetic.

METHOD FOR BLOOD Find an assistant. Sedate the patient, sit him up, and lean him forwards over a bed table or a pile of pillows.

Sit on a stool beside his bed, and percuss his chest to find the area of maximum dullness. This is usually over his sixth, seventh, or eighth rib in his posterior axillary line.

Use a fine needle to infiltrate a little local anaesthetic into the tissues at the site of the aspiration. Nick his skin with a scalpel blade parallel to his ribs. Push a large needle on the end of a 10 or 20 ml syringe slowly into his chest wall through the nick, pulling back the plunger as you do so.

Remove the syringe as soon as it fills with blood or fluid, and put a swab on the hole. Record your findings and the site of the puncture accurately in his notes.

INSERTING A CLOSED INTERCOSTAL DRAIN

A CHEST SET consists of: (1) A large trocar and cannula 8.3 mm (25 Ch). (2) A 24 to 30 Ch Malecot or de Pezzer catheter which just fits through the trocar. (3) A metre of 8 mm (24 Ch) plastic or rubber tube to join the catheter to the bottle, using a connector. if you don’t have a suitable catheter, you can push the end of this tube through the trocar into the chest. if you do, the tube must be thick and stiff enough not to collapse when it goes through the chest. If convenient, you can use a thinner tube (5 mm, 16 Ch) for draining air. (4) A drainage bottle (Tudor–Edwards) complete with a cork and two tubes. Adjust the size of the bottle to the size of the patient. A child needs only a small bottle. (5) A needle holder. (6) Stout artery forceps to clamp the tube. (7) A No. 4 scalpel with a No. 23 blade. (8) Some No.1 monofilament. (9) Ordinary stitch scissors. (10) Gauze swabs and a gallipot.

Wrap all this equipment together in a green towel, put it in a tray, tie it up with bandages, and autoclave it. Have it always ready sterile, as in Fig. 65-4.

USING A TROCAR AND CANNULA Position the patient, and find the point of maximum dullness as for aspiration.

Infiltrate the place where the tube is to go with anaesthetic solution as in A, Fig. 65-6. Push the needle down to the rib infiltrating as you go. Inject the solution in 1 ml portions, aspirating between each injection. Try to anaesthetize the patient’s pleura without entering his pleural cavity. if necessary, anaesthetize one space above and one below the site of insertion of the tube.

Alternatively, block the intercostal nerve (A 6.7) 1 cm proximal to where you intend to introduce your cannula.

Apply the first pair of artery forceps some way up the tube (B, Fig. 65-6). It will both clamp the tube, and serve as a gauge as to how much tube there is inside the chest. There must be at least 2 cm (for the free end of the tube in the pleural cavity), plus one chest wall thickness (which will vary with the patient’s build), plus the length of the cannula, plus 4 cm spare.

Apply the second forceps to the distal end of the tube.

Nick the patient’s skin with the scalpel blade (C), push the trocar and cannula through the infiltrated area into his pleural cavity (D).

Pull out the trocar (E) and quickly push the tube down the cannula (F). Then pull out the cannula up as far as the first forceps, leaving the tube in his chest. The first pair of artery forceps ensures that the depth of tube inside his chest is just right. Apply the second pair of artery forceps close to his chest wall (G) and remove the cannula from the tube. Ask your assistant to connect the tube to an underwater seal drain as described below.

Release the artery forceps. Anchor the tube to his chest wall with a safety pin and adhesive strapping, or, better with a stitch. Alternatively, use strapping as in Fig. 65-8.

Connect the catheter to an underwater seal drain.

CAUTION! Don’t let air get into his chest through the tube. Apply the artery forceps as above, and don’t release them until the tube is connected to the underwater seal. if there is any delay in putting the tube into the cannula, plug it with your finger.

ALTERNATIVE USING A SCALPEL, ARTERY FORCEPS, AND A CATHETER

Use a scalpel with a No. 11 blade to make a 1 cm incision down to the upper edge of the rib and then through the intercostal space for about 3 mm. Avoid its lower edge, because the intercostal vessels run there. Push a pair of artery forceps or scissors down the incision, and by blunt dissection open up a track down to the pleura. Try not to enter it with the scalpel.

Clamp the catheter with artery forceps, hold the other end of it with another pair of artery forceps, and push it down the track into the pleura, as in H, Fig. 65-6. Alternatively, you can insert a Malecot or de Pezzer catheter on an introducer.

DRAINING AIR FROM THE PLEURAL CAVITY

Using any of the methods above, puncture the patient’s third intercostal space well outside his midclavicular line, and lead the tube into an underwater seal drain.

MAKING AN UNDERWATER SEAL DRAIN FOR A CHEST INJURY

Take a 3 to 5 litre glass bottle with a large top, and a cork with two holes. Put a litre of water or dilute antiseptic into the bottle. Pass two glass tubes through cork and let one tube go down 5 cm below the level of the fluid. Connect the top end of the long glass tube to the rubber tube draining the patient’s chest. Make sure the fit is airtight. The rubber tube must be long enough so that, if he moves about, he does not detach it from the bottle or raise it above the water level.

Ask him to cough. Blood or bubbles should come out of the tube.

Keep a pair of artery forceps near by, so that the rubber tube can be clamped if it becomes detached from the bottle. Fix a piece of strapping to the bottle, and mark the upper level of the fluid on it, so that you can measure how much blood or exudate is discharged.

When the bottle is changed, clamp the rubber tube with the forceps, and release them only when the bottle has been reconnected.

If necessary, you can join the tubes from the top and bottom of the patient’s chest with a Y–connector and drain them into one bottle.

Measure the volume of blood that drains and transfuse the patient as necessary.

CAUTION! (1) The end of the tube must be 5 cm below the level of the water so that if the pressure in the chest rises above this, air or fluid will be blown off. It is an underwater seal. (2) Make sure that the nurses understand what the bottle is for and that nobody disturbs it. If anybody raises it above the level of the patient’s chest, the water and antiseptic in the bottle may go into his pleural cavity!

Alternatively, arrange 2 bottles, as in D, Fig. 65-5. This will allow you to collect the exudate separately from the fluid.

DIFFICULTIES DRAINING THE CHEST

If you have NO SPECIAL BOTTLE, use any large bottle such as the plastic bottle in B, Fig. 65-5 and lead the tubing under the surface of the water. Hold it in place with adhesive strapping. If you want to see the water moving in the tube, fix a piece of glass tubing into the end of the plastic tube. You can use the narrow tube from a drip set, but this is not nearly so effective.

THE TUBE MUST NOT COME OUT ACCIDENTLLY