THORACENTESIS

1. Indications in the ER are for diagnostic purposes, or if  the amount of fluid is large enough to shift trachea and interfere with breathing.
    
2. To assess if  fluid is loculated, obtain ipsilateral decubitus x-ray.
    
3. You will  need iodine, Lidocaine, thoracentesis kit (or 20 gauge needle, IV tubing and vacuum bottles).
    
4. Place patient in sitting position with arms resting on bedside stand.
    
5. Percuss for dullness, prep and inject local anesthetic. Unless otherwise indicated, the perfect site is  medial to scapula or 5-10 cm from spine at level of  6th IC space. This site can be located by either palpating T6  or the 6th  rib .
    
6. Insert needle above interspace.  Advance needle slowly while aspirating, and once return of fluid is appreciated, syringe is removed to avoid pneumothorax. Place finger on needle opening to avoid inflow of air.
    
7. Apply IV tubing and aspirate fluid for analysis or therapeutic purposes. For result interpretation see  "Pl. Effusion" section below.

Do not  remove more than 1500 ml of fluid. This  may cause both hypotension and  hypoxia (rapid V/Q mismatch). A CXR must be obtained at the completion of the procedure to rule out a pneumothorax.

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