Emergency Medicine

INTERCOSTAL CATHETER INSERTION

Practical Procedures 473

5 Infection at the skin site.

6 Spleen or liver injury.

7 Air embolism.

8 Empyema.

INTERCOSTAL CATHETER INSERTION

INDICATIONS

1 Drainage of a significant pneumothorax, haemothorax, large pleural
effusion or empyema.

2 Prophylactic insertion prior to positive-pressure ventilation or aeromedical
transport, in a patient with a chest injury and rib fractures or f lail chest, or
even a small pneumothorax.

CONTRAINDICATIONS

1 Infection over insertion site.

2 Uncorrected bleeding diathesis (in particular platelets <50 or INR >1.5).

TECHNIQUE

1 Review recent CXR and confirm the side, position and size of the pneumo-
thorax/f luid.

2 Give analgesia 0.05–0.1 mg/kg morphine i.v., and or 0.05 mg/kg midazolam
i.v., titrated to effect in the haemodynamically stable patient, as the proce-
dure is painful and potentially distressing.

3 Select appropriate size of chest tube:
(i) Adult 16–22 F for pneumothorax, or 28–32 F for effusion,
haemothorax or empyema.
(ii) Child 12–20 F, or newborn 10–12 F.

4 Infiltrate generously with local anaesthetic down to the pleura in the fifth
intercostal space in the mid-axillary line.

5 Use a scalpel blade to incise the skin and subcutaneous fat, then blunt dissect
down to and through the parietal pleura.

6 Slide the drain in gently with a pair of curved artery forceps having removed
the trocar. Connect the drain to an underwater seal, and confirm it swings
with respiration.

7 Secure the chest tube in place and check position of chest tube with a post-
procedure CXR.