Chest Drain Insertion in Adult Trauma

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Question 1 of 10

1. Question
Which one of the following patients has clear indication for chest drain insertion in the ED?
- A 19-year-old man stabbed in the right side of his chest posteriorly with a moderate sized pneumothorax
- A 35-year-old man who has fallen 8m with fractured ribs 5-7 on the left side. His chest x-ray is otherwise unremarkable. The injury appears isolated, though he does have respiratory distress, possibly because of pain
- A 26-year-old male with a small haemothorax secondary to a rib#, detected on CT
- A 46-year-old woman with an occult pneumothorax detected on CT. There is no current plan for her to be ventilated
- A 74-year-old woman with a small isolated traumatic pneumothorax following a road traffic accident
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Question 2 of 10

2. Question
A 64-year-old woman has fallen off her horse. You elicit crepitus over her left ribs laterally. Her chest x-ray confirms fractured left fifth and sixth ribs with an associated moderate haemopneumothorax.

Which of the following are safe landmarks for chest drain insertion given this information.
- Second intercostal space, mid clavicular line
- Fourth intercostal space midaxillary line
- Fifth intercostal space more anteriorly
- Seventh intercostal space mid axillary line
- No landmark is required. Opt for conservative management, observing her carefully
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Question 3 of 10

3. Question
A large 84-year-old woman has fallen down the stairs. Her injuries are a moderate haemopneumothorax right side, a fractured right wrist requiring manipulation and a skin flap laceration to her left tibia. There is no indication of a head injury.

Which of the following are reasonable options in pre-emptively relieving the pain and anxiety of chest drain insertion?
- Lignocaine, up to 3 mg/kg
- Titrated IV midazolam
- Titrated IV morphine
- Entonox
- IV midazolam and morphine
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Question 4 of 10

4. Question
You proceed to insert a chest drain into the same 84-year-old woman. Having anaesthetised the skin, you fail to aspirate air or blood when inserting a 21G needle perpendicular to the skin in the fifth intercostal space, midaxillary line.

Which of the following might account for this?
- Misjudgement of the true site of the fifth intercostal space
- Her thick chest wall
- Misinterpretation of the chest x-ray
- Occlusion of the needle with tissue from passage through the chest wall
- A non-perpendicular route through the chest wall
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Question 5 of 10

5. Question
You are supervising a junior doctor inserting a chest drain into a 70 kg man with a large traumatic pneumothorax. The doctor asks how far to insert the chest drain? What is your response?
- Insert the chest drain halfway
- Insert all the way, leaving enough room to secure the drain
- Insert the chest drain in sufficiently, so that the proximal hole of the chest drain lies within the pleural cavity
- Insert the chest drain until the patient tells you it's become uncomfortable
- Insert 15 cm into the patient's chest
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Question 6 of 10

6. Question
Examine this chest x-ray.

Which of the following statements are correct?
- The drain is clearly within the pleural cavity
- The drain appears appropriately placed in order to drain the haemothorax
- The drain lies within a fissure
- The drain appears to have been inserted to the appropriate length
- The drain is not within the pleural cavity
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Question 7 of 10

7. Question
Which of the following statements regarding antibiotic cover following chest drain insertion in injured patients are correct?
- The empyema rate following chest drain insertion in injured patients without antibiotic cover is between 5 and 10%
- 24-hour IV cephalosporin cover provides statistical, but not clinically relevant effect
- 24-hour IV cephalosporin cover reduces the empyema rate to <1% with an NNT <6
- 24-hour IV cephalosporin cover reduces the empyema rate to <1% with an NNT 10-40
- 24-hour IV cephalosporin cover reduces the empyema rate to <1% with a NNT >40
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Question 8 of 10

8. Question
In which one of the following scenarios is clamping the chest drain appropriate?
- Sudden deterioration in oxygen saturation
- Patient transfer
- Chest drain not swinging
- Abrupt and continuous blood loss resulting in profound clinical deterioration
- Contrast phase of CT imaging
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Question 9 of 10

9. Question
Which of the following reliably indicate that the chest drain lies within the chest cavity?
- Fogging of the drain
- CT chest
- Chest x-ray
- Swinging of the chest drain with respiration
- Improving clinical status
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Question 10 of 10

10. Question
Which of the following statements regarding the National Patient Safety Agency report on the risks of chest drain insertion are correct?
- The injuries described are confined to the traditional method of chest drain insertion, rather than Seldinger
- Poor patient positioning and inappropriate site of insertion are two key errors resulting in patient harm
- Written consent is recommended
- Ultrasound guidance for haemothoraces is recommended
- The most common cause of death attributed to poorly performed chest drain insertion is puncturing a major organ.
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Chest Drain Insertion in Adult Trauma

Chest Drain Insertion in Adult Trauma

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