title: Guidelines for chest drain insertion may not prevent damage to abdominal viscera.
abstract: OBJECTIVE
  Guidelines to improve the ease and safety of chest drain insertion recommend using the fifth intercostal space, around the midaxillary line (MAL). This study aimed to assess whether compliance with published guidelines reliably ensured such placement and avoided the potentially serious complications of subdiaphragmatic insertion and peripheral nerve injury.
  
  
  METHODS
  Three international guidelines were assessed by identifying the intercostal space for chest drain insertion using 16 cadavers (32 sides) at a point 1 cm anterior to MAL. The European Trauma Course method was compared with the British Thoracic Society's 'safe triangle' and the ATLS course technique.
  
  
  RESULTS
  The level most commonly found was the sixth intercostal space (43%; 41 of 96 sides). Overall the sixth space or below was found in 83% of insertions (80 of 96 sides). In the fifth intercostal space, the long thoracic nerve ran posterior to the marker placed in all cases and the lateral cutaneous branches of intercostal nerves arose anteriorly to the marker in all but one case.
  
  
  CONCLUSIONS
  The results suggest these guidelines may result in insertion of chest drains below the fifth intercostal space, potentially risking injury to subdiaphragmatic structures. Peripheral nerves of the lateral thoracic wall appear safe from incisions 1 cm anterior to MAL.
authors.affiliation: School of Medicine, University of St Andrews, St Andrews, Fife, UK.
authors.forename: J
authors.initials: J
authors.lastname: Bowness
authors.affiliation: School of Medicine, University of St Andrews, St Andrews, Fife, UK.
authors.forename: P M
authors.initials: PM
authors.lastname: Kilgour
authors.affiliation: School of Medicine, University of St Andrews, St Andrews, Fife, UK.
authors.forename: S
authors.initials: S
authors.lastname: Whiten
authors.affiliation: School of Medicine, University of St Andrews, St Andrews, Fife, UK.
authors.forename: I
authors.initials: I
authors.lastname: Parkin
authors.affiliation: Faculty of Medical & Human Sciences, Manchester Medical School, University of Manchester, Manchester, Manchester, UK.
authors.forename: J
authors.initials: J
authors.lastname: Mooney
authors.affiliation: School of Medicine, University of St Andrews, St Andrews, Fife, UK.
authors.forename: P
authors.initials: P
authors.lastname: Driscoll
mesh_terms: D000007:Abdominal Injuries / Q000517:prevention & control*; D000368:Aged; D000369:Aged, 80 and over; D002102:Cadaver; D015505:Chest Tubes; D004322:Drainage / Q000379:methods*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D013907:Thoracostomy / Q000379:methods; D014781:Viscera / Q000293:injuries*
keywords: Trauma; Trauma, chest; abdomen; doctors in PHC; emergency department