3 In a quoted example: ‘Chest drain penetrated the heart and the patient had a cardiac arrest when it was removed’. The National Patient Safety Agency recently found at least 12 deaths and 15 cases of severe harm directly attributable to chest drains over three years puncture of the heart, lung and liver were reported, most commonly with the Seldinger technique. Iatrogenic cardiac injuries due to chest drain insertion are rare but often fatal. In our case, the subsequent CT demonstrated lung collapse with displacement of the heart towards the chest wall, increasing the likelihood of cardiac puncture with the technique employed. 1 Similarly, when using the Seldinger technique, the BTS state that a drain should not be inserted without imaging ‘if free air or fluid cannot be aspirated with a needle’. In such cases, there is greater risk of injury to underlying structures and the drain should be placed under image guidance such as real-time ultrasound. 2 In addition, thoracic pathology including kyphoscoliosis, lung volume loss or a complex pleural space may lead to displacement of the mediastinum, tethering of the lung or elevation of the hemidiaphragm. In a recent survey of junior doctors in a UK teaching hospital, 45% opted to place a chest tube outside of the safe triangle, most commonly at a site deemed too low. Complications most commonly occur when the drain is placed outside of this zone, as in our case. This area is formed by ‘the anterior border of latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla’. The BTS describe a truncated ‘safe triangle’ through which tube placement is advocated to minimize risk of injury to underlying structures. Complications occur in up to 20% of patients including failure to enter the pleural space, early tube dysfunction and laceration of the lung. 1 The left lung field whiteout with the trachea deviated towards the pathology in this case is classical for collapse and therefore chest drainage is not indicated.Ĭhest drain insertion is a procedure commonly performed by many physicians and surgeons. The British Thoracic Society (BTS) has published guidelines on the insertion of chest drains and advise that ‘it is important to differentiate between the presence of collapse and a pleural effusion when the chest radiograph shows a unilateral whiteout’. Finally, when an entire lung is surgically removed, there is volume loss with subsequent fluid accumulation and fibrotic opacification of the pleural space a resected rib may be absent on the radiograph although this diagnosis should be clinically apparent. In consolidation due to pneumonia, there is typically no mediastinal shift and an air bronchogram may be seen against the consolidated lung. On the other hand, a large pleural effusion exerts a mass effect, pushing the trachea away from the affected side. In atelectasis, there is volume loss of the affected lung resulting in mediastinal shift towards the opacification. Hemithorax opacification on chest X-ray has four potential causes: collapse (atelectasis) of an entire lung pleural effusion consolidation and post-pneumonectomy.
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