Chest Tube Insertion

Editorial Team / Moderator · Apr 10, 2017

Depends on the situation. In trauma we can usually get the patient some meds prior to insertion (I think we did some Versed and fentanyl with the last one if memory serves), but if a patient is hemodynamically unstable, then it varies. Sometimes the chest tube is lifesaving, like with a tension pneumo or if they have a big hemothorax and are bleeding out into the chest and need autotransfusion. In those cases, time is a factor.

BeeU_RN · Apr 10, 2017

Thanks for your input! This was definitely a very stable patient who presented to our ED with chest congestion which ended up being a pneumo. There was definitely time to get some meds on board.

bgxyrnf, MSN, RN · Apr 13, 2017

I've seen it run the gamut from conscious sedation to nothing but a local. Generally, for a patient such as yours, fentanyl titrated to effect, along with the local.

No meds, or even just 2 of MS, seems positively barbaric in a stable patient.

AJJKRN · Apr 13, 2017

Yep, my place would have done the moderate sedation route with some versed and some fentanyl. Our facility requires all ED, ICU, and float RN's to be competent (aside from all the other RN's that do moderate sedation as their mainstay).

BedsideNurse · Apr 13, 2017

In ICU we usually give Fentanyl and Versed + local and that seems to do the trick just fine....Years ago I had a tension pneumo and they placed a chest tube with just local. For me it wasn't painful; basically just tolerable pressure (vs. the *completely* intolerable chest pressure of a tension pneumo).

AnnieOaklyRN, BSN, RN, EMT-P · Apr 13, 2017

Hi,

as others have said it depends on the physician and their comfort level with sedation. I find when the general surgeons do it, they often do not sedate well enough. Our ED docs which often times use Fentanyl and Versed or just order Propofol, which my opinion is the best option.

Chest tubes are VERY painful and I think it's kind of inhumane when they do not sedate well enough, unless there are good reasons not to like BP etc.

Annie

Editorial Team / Moderator · Apr 13, 2017

Have any of you seen the UreSil Thora-Vent used for simple pneumos? They are awesome! Much less traumatic for the patient, too.

CCU BSN RN · Apr 14, 2017

I have literally seen a PA place a chest tube on a stable patient with nothing but a local. He had a huge effusion, but stable on NRB and could've waited for IR to be called in. But alas, no. And I don't mean a little heimlich or a pigtail, I mean a 32 french pleural tube involving some pretty gnarly blunt dissection. This was on a tele floor where we weren't moderate sedation trained, and it was a surgical service that wouldn't have ordered anything anyway.

It was scarring, and one of those defining moments as a new grad where you realize, 4 years later, that you should've done more than hold the patient's hand and distract him. That you should've demanded SOMETHING.

Lev, MSN, RN, NP · Apr 23, 2017

At my old ED, some morphine + local was standard. At my new ED, have not seen a chest tube a month in. This is what I signed up for I guess...Sighs...

akulahawkRN, ADN, RN, EMT-P · Apr 23, 2017

Lidocaine works pretty well but it has to be well infiltrated into the tissues for it to work like it should. This means using a LOT of it. A couple mL of 1% or 2% isn't going to do the trick. I've had a local done for a procedure (cyst removal) and that went fine, the PA used around 5 mL total of 1% Lidocaine. That being said, tissues below the dermis weren't infiltrated. Most of the procedure was quite pain-free. Those few places that the Lido wasn't infiltrated, I experienced quite a bit of pain. I suspect providers are probably concerned about Lidocaine toxicity OR they're only used to doing a "topical" local so the deeper tissues aren't well infiltrated, so while the incision may be painless, the blunt dissection through the pleural space is horribly painful.

The only time I would consider it OK to place a chest tube in an non-anesthetized patient is when the patient is so unstable that waiting for the lido to take effect could be lethal.

For the record, no I don't place them in my practice as a Paramedic or an RN. I'm familiar with the procedure, but I am only authorized to do needle thoracostomies in my Paramedic Practice.

Quota, BSN, RN · May 17, 2017

I can speak on this from the patient side of things. I've got primary spontaneous pneumothorax and have been hospitalized a handful of times with chest tubes. Gone through surgery on both lungs now so chances of a repeat pneumothorax are very low.

Pretty sure the first time I had a significant collapse and actually sought medical attention I had a UreSil Thora-Vent or something similar (back in 2000 so possibly different). The insertion site was numbed so I just felt pressure but no pain during placement. Not too long after though the pain started to radiate to my shoulder and arm, they pushed morphine then. The next major collapse they used a sedative, I was stable so time wasn't an issue. I'm pretty sensitive to narcotics so things are kind of fuzzy after they gave me the sedative. I was aware something was happening when they placed the chest tube but no pain was involved. All other chest tubes I've had were placed during surgery so I was out for that.