Management of Traumatic Pneumothorax and Haemothorax in the Emergency Department
Executive Summary
The management of traumatic pneumothorax (PTX) and haemothorax (HTX) in the Emergency Department (ED) has evolved towards a more nuanced, evidence-based approach that balances life-saving intervention with the minimization of procedural complications. Traditional large-bore drains (24–40F) remain the standard for haemothorax and unstable patients, but recent research confirms that small-bore percutaneous (Seldinger) drains (≤14F) are equivalent for isolated, stable pneumothoraces and are better tolerated by patients.
Clinical decision-making must be stratified by patient physiology. Unstable or peri-arrest patients require immediate clinical decompression via finger thoracostomy. Stable patients should be managed based on imaging cut-offs (>35mm or >20% volume) and the presence of symptoms. Adherence to National Safety Standards for Invasive Procedures (NatSSIPs 2) and the use of procedural checklists are mandatory to mitigate the significant risks of malposition, visceral injury, and retained guidewires. For securing drains, the modified JoBerg technique combined with Hollister attachment devices and evidence-based taping methods (Cross-taping or Bridge method) is recommended to prevent accidental dislodgement.
Definition and Classification
• Pneumothorax (PTX): The presence of air within the pleural space.
◦ Simple: No significant physiological compromise.
◦ Tension: A life-threatening condition where air enters the pleural space but cannot escape, causing mediastinal shift and obstructive shock.
◦ Occult: Not visible on plain radiograph but identified on CT.
• Haemothorax (HTX): The presence of blood within the pleural space, often quantified by imaging (e.g., >300mL or >1.5cm pleural gutter thickness on CT).
• Classification by Procedural Technique:
1. Open/Blunt Dissection: Involving an incision and blunt dissection of the intercostal muscles. Required for large-bore drains (>24F) and HTX.
2. Percutaneous (Seldinger): Involving a guidewire and dilator. Preferred for simple PTX and small effusions.
Epidemiology and Aetiology
• Incidence & Predominance: While specific incidence rates vary, traumatic PTX/HTX is a hallmark of major trauma. It frequently occurs in males involved in high-energy mechanisms (e.g., road traffic collisions, falls from height).
• Aetiology:
◦ Blunt Trauma: Falls (e.g., from horses, windows), assaults, and vehicle collisions. Often associated with rib fractures.
◦ Penetrating Trauma: Stabbings or gunshot wounds, which mandate prophylactic antibiotics.
• Predisposing Factors: Pre-existing bullous lung disease, chronic obstructive pulmonary disease (COPD), or alcoholism (associated with higher risk of trauma and infection).
• Pathology: Macroscopic pathology involves lung parenchymal injury or vascular disruption. In HTX, blood may clot, rendering small-bore drains useless.
• Prognosis: Excellent with timely decompression; however, failure to recognize tensioning or massive HTX leads to rapid cardiovascular collapse.
Clinically Relevant Anatomy
The "Triangle of Safety" is the primary landmark to minimize injury to the long thoracic nerve and internal mammary artery.
• Boundaries:
◦ Anterior: Lateral edge of pectoralis major.
◦ Posterior: Lateral edge of latissimus dorsi.
◦ Superior: Base of the axilla.
◦ Inferior: 5th intercostal space (ICS).
• The Neurovascular Bundle: Situated at the inferior border of each rib. Rule: Always pass the drain/instrument over the superior border of the lower rib to avoid the bundle.
• Mid-Arm Point: For identifying the level of insertion, the mid-arm point (shoulder tip to antecubital fossa) is the preferred evidence-based landmark. In pregnant patients, the incision should be one ICS higher due to diaphragm elevation.
Clinical Assessment
Clinical assessment must follow the ABCDE structure.
Airway (A)
• Ensure patency. In tension PTX, tracheal deviation is a late and unreliable sign.
Breathing (B)
• Symptoms: Respiratory distress, pleuritic chest pain.
• Signs: Decreased breath sounds, hyper-resonance on percussion (PTX) or dullness (HTX), decreased saturations, and tachypnoea.
• Ventilated Patients: Markedly increased resistance to "bagging" or high airway pressures on the ventilator are critical indicators of tension PTX.
Circulation (C)
• Hypotension and tachycardia indicate tension PTX (obstructive shock) or massive HTX (haemorrhagic shock).
• Likelihood Ratios: While not provided for all signs, the combination of hypoxia and hypotension in the context of thoracic trauma warrants immediate intervention without waiting for imaging.
Disability (D) and Exposure (E)
• Assess for GCS and lateralizing signs.
• Full exposure is required to identify penetrating wounds or "seatbelt signs."
Key Investigations and Interpretation
Modality | Threshold for Intervention | Notes |
|---|---|---|
CXR (Upright) | >38mm lung-to-chest wall distance or >20% volume | Estimation is imprecise; upright films are more reliable than supine. |
CT Chest | >35mm max lung-to-chest wall distance | Gold standard for stable patients and quantifying HTX (>300mL). |
POCUS | Absent lung sliding + hypoxia/hypotension | Justifies chest tube even if supine CXR is normal. |
Treatment and Summary of Evidence
Conservative Management
Acceptable in stable patients with:
• Isolated, small traumatic PTX (no IPPV planned).
• Occult PTX on CT with a normal CXR and no respiratory distress.
Intervention Indications
• Emergency: Tension PTX, traumatic cardiac arrest (bilateral), HTX seen on CXR, or PTX in patients requiring mechanical ventilation.
• Drain Sizing:
◦ Pneumothorax (Stable): 14F–22F. 14F Seldinger is equivalent to larger tubes for PTX.
◦ Haemothorax/Unstable PTX: 24F–28F (Large-bore).
◦ Massive HTX: 32F–36F may be required.
Step-by-Step Procedure Guidance
1. Open Thoracostomy (Blunt Dissection)
1. Consent & Time Out: Use NatSSIPs/LocSSIPs checklist.
2. Position: Patient at 45° or supine with arm abducted 90°.
3. Site: Identify 4th/5th ICS in the triangle of safety using the Mid-Arm Point.
4. Anaesthesia: Infiltrate 1% Lidocaine (max 3mg/kg) to skin, muscle, and periosteum. Stop if air/blood cannot be aspirated.
5. Incision: 4cm transverse incision parallel to the rib.
6. Dissection: Use curved clamps (Howard Kelly) to bluntly dissect through muscle.
7. Pleural Entry: Pierce the pleura over the superior rib margin. A "give" and "gush" of air/blood confirms entry.
8. Finger Sweep: Insert finger to 360° sweep to ensure no adhesions/visceral contact (use double gloves for rib fracture protection).
9. Insertion: Mount the drain on a clamp and guide into the pleural space. Confirm with "fogging" and "swinging."
2. Percutaneous (Seldinger) Insertion
Indicated for stable PTX or simple effusions.
1. Follow steps 1–4 of Open technique.
2. Needle: Insert into the pleural space while aspirating.
3. Guidewire: Pass through the needle; remove the needle.
4. Dilatation: Pass the dilator over the wire (do not advance more than 1cm beyond the parietal pleura).
5. Drain: Pass the drain over the wire, remove the wire, and secure.
Paediatric Management
• The Rule of 4: Employ this mnemonic for sizing and depth (sizing 4x ETT size or appropriate weight-based WATCh sheet guidance).
• Site: Use the mid-arm point for identification, similar to adults.
Securing the Drain and Post-Procedural Care
• Modified JoBerg Technique: Use '1' silk to secure. Perform mattress sutures. Create a knot 10cm high, then wrap ends firmly around the drain (double D half hitches) and tie.
• Hollister Device: Advocate for the Hollister adhesive attachment device to minimize skin tugging and accidental removal.
• Taping:
◦ Cross-taping: Demonstrated as the most secure method for the junction between the tube and the drainage system.
◦ Bridge Method: Superior for affixing the tube to the skin (withstands up to 52N of force).
• Analgesia: Prescribe regular analgesia; consider intrapleural bupivacaine via the drain for additional relief.
• Underwater Seal: Must always remain below the level of the chest. Prime with Saline (not water) to allow for cell salvage in massive HTX.
Complications and Management
Complication | Timeframe | Management |
|---|---|---|
Malposition (Lung Fissure) | Immediate | Check CXR; if functional (swinging/fogging), do not reposition solely based on X-ray. |
Visceral Injury (Lung/Liver/Spleen) | Immediate | Immediate surgical referral. Avoid Trocar use. |
Retained Guidewire | Immediate | Audit all items during Sign Out. Report as a "Never Event" if not retrieved. |
Infection (Empyema/Pneumonia) | Delayed | Prophylactic antibiotics (e.g., 2g Cefazolin) for penetrating trauma and all open drains. |
Drain Fall-out | Delayed | Use holding sutures; doubling the risk if omitted. |
Re-expansion Pulmonary Edema | Delayed | Manage effusions carefully: drain <500mL in the first hour and <1500mL in 24 hours. |
References
1. Lloyd G, Fordham S. Chest Drain Insertion in Adult Trauma. RCEMLearning. 2019 (Updated 2024).
2. Bansal S, Zhao R, Hosein R. Chest Drain Insertion: A practical guide. RCEMLearning. 2020 (Updated 2024).
3. Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58(Suppl II):ii53-ii59.
4. British Thoracic Society. Online Appendix 4: Intercostal drain insertion. BTS Pleural Disease Guideline 2010.
5. Royal College of Emergency Medicine. Best Practice Guideline: Invasive Procedures in the Emergency Department. 2023.
6. Li KKP, Wong KSJ, et al. How to secure the connection between thoracostomy tube and drainage system? World J Emerg Med. 2014;5(4):259-263.
7. Domanska K, O’Sullivan A, et al. Tape it up: scientific experiment testing the best taping method for intercostal chest drains. Emerg Med J. 2023.
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EPIC EHR Documentation Structure
Intercostal Catheter (Chest Drain) Insertion Record
Pre-Procedure Checklist
• [ ] Patient identity verified
• [ ] Written/Verbal consent obtained (or Best Interests documented)
• [ ] Side confirmed by two clinicians (one ST4+)
• [ ] Imaging reviewed (CXR/CT/POCUS)
• [ ] Site marked (Triangle of Safety / Mid-Arm Point)
• [ ] Anticoagulation/Coagulation status reviewed
• [ ] Appropriate analgesia/sedation administered (e.g., Ketamine/Morphine)
Procedure Details
• Indication: [ ] Pneumothorax [ ] Haemothorax [ ] Tension [ ] Other: ______
• Technique: [ ] Open (Blunt Dissection) [ ] Percutaneous (Seldinger)
• Side: [ ] Left [ ] Right
• Level: [ ] 4th ICS [ ] 5th ICS [ ] Other: ______
• Local Anaesthetic: [ ] 1% Lidocaine [ ] 2% Lidocaine | Volume: ______ mL
• Aspiration prior to incision: [ ] Yes [ ] No
• Finger Sweep performed: [ ] Yes [ ] No
• Drain Size: [ ] 14F [ ] 20F [ ] 24F [ ] 28F [ ] 32F [ ] 36F
• Suture Material: [ ] 1-0 Silk [ ] 2-0 Silk [ ] Other: ______
• Securing Method: [ ] Modified JoBerg [ ] Hollister Device [ ] Cross-taping junction
Sign Out & Verification
• [ ] Guidewire removed (if Seldinger)
• [ ] Fogging noted in tube
• [ ] Swinging/Bubbling noted in underwater seal
• [ ] Underwater seal primed with SALINE
• [ ] Sharps disposed of by proceduralist
• [ ] Post-procedure CXR requested
Medical Decision Making (MDM) Patient presented with [History/Mechanism]. Clinical findings of [Signs/Symptoms] and imaging [CXR/CT Findings] confirmed [Diagnosis]. Emergent/Urgent decompression was indicated due to [Physiological parameters]. Procedure was performed using [Technique] without/with complications [List complications]. Post-procedure care includes [Analgesia/Monitoring/Antibiotics]. Handover provided to [Surgical/ICU Team].
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