Chest Drain — Open Technique

Indications

• Traumatic haemothorax / haemopneumothorax — the standard indication per ATLS; needs a large-bore (28–32F) drain because small-bore drains block with clot.
• Traumatic pneumothorax in a ventilated patient, or before transfer/air transport, given the risk of tension developing under positive pressure ventilation.
• Finger thoracostomy — in traumatic cardiac arrest, or as a rapid temporising step in a peri-arrest ventilated trauma patient, performed instead of formal tube insertion when speed is paramount; a drain can follow once the patient stabilises.

Contraindications & cautions

Preparation

• In a peri-arrest or arrested trauma patient, act immediately — do not wait for full aseptic set-up or formal consent.
• In a stable patient: consent, confirm side and site against imaging, IV access, analgesia and sedation as appropriate, full aseptic technique.
• Position: supine with the arm on the affected side abducted/behind the head, exposing the safe triangle.
• Have blood products available or requested if haemothorax is suspected — significant blood loss is likely.

Equipment

Site — the safe triangle

Same landmark as the Seldinger technique: the safe triangle, bordered by the lateral edge of pectoralis major (anterior), the lateral edge of latissimus dorsi (posterior), and the line of the 5th intercostal space (inferior), apex at the base of the axilla.

Step-by-step technique

1. Anaesthetise (if time allows)

   Infiltrate skin, subcutaneous tissue, intercostal muscle and pleura with lidocaine in the stable patient; omit in traumatic arrest where seconds matter.

   LAST rescue — AAGBI algorithm ↗

2. Incision

   Make a 2–3 cm incision along the line of the rib, one intercostal space below the planned entry point, through skin and subcutaneous tissue.

3. Blunt dissection

   Use closed curved clamps to bluntly dissect through the subcutaneous tissue and intercostal muscles, walking over the top of the rib below to avoid the neurovascular bundle, until the clamp tip is felt to "give" through the parietal pleura.

4. Finger sweep

   Insert a gloved finger through the tract into the pleural space to confirm entry, sweep for adhesions, clots or diaphragm, and to keep the tract open — this is finger thoracostomy in its own right if a drain is not yet being placed.

5. Insert the drain

   Guide the drain into the pleural space with a clamp or finger as a guide — never with a trocar — directing it apically for pneumothorax or basally/posteriorly for haemothorax, to the desired depth.

6. Connect and confirm

   Connect immediately to the underwater seal; confirm swinging and bubbling/drainage.

7. Secure

   Suture the drain in place with a robust stitch, and dress; document initial drainage volume.

Complications

Massive haemothorax — thresholds for cardiothoracic escalation

• ATLS defines massive haemothorax by an immediate drainage of >1500 mL of blood on chest drain insertion, or ongoing drainage of >200 mL/hour for 2–4 consecutive hours, or the ongoing need for blood transfusion to maintain haemodynamics.
• Any of these should prompt urgent discussion with cardiothoracic surgery/theatre for consideration of thoracotomy, alongside major haemorrhage protocol activation.
• Autotransfusion of drained blood may be considered locally where facilities and protocols exist.

Pitfalls & pearls

• Never use a trocar — blunt finger/clamp dissection every time.
• In traumatic cardiac arrest, think bilateral finger thoracostomies before formal drains.
• Direct the drain basally/posteriorly for blood, apically for air — adjust per the clinical picture.
• Send early volume drained and trend hourly output — this is what drives the cardiothoracic conversation, not a single number in isolation.
• A 12F Seldinger drain will block with clot in trauma — always go large-bore open technique for haemothorax.

References