Conservative, expectant treatment is safe in my opinion,as long as you
admit him to a well monitored unit and have clear arrangements for a
competent registrar to attend promptly and insert a chest drain should
his pneumothorax expand.Graham Johnson wrote up a series of 30 or so of
these in JAEM a couple of years ago.
I have had the same problem, Simon - once referred & admitted to the
surgical wards, our greater experience in this area is ignored and the
patient undergoes a painful, dangerous, even disfiguring procedure which
prolongs length of stay. The technique often leaves something to be
desired! I worry that sometimes it is done because the doctor wants the
experience.....
As a result, we usually admit them to our obs ward for expectant
treatment under our own care, though this necessitates 24 hour on site
registrar cover in my opinion.
steve meek
emergency department
RUH Bath
> ----------
> From: Simon Carley[SMTP:[log in to unmask]]
> Sent: 10 September 1996 11:03
> To: acadae messages
> Subject: conservative tx of traumatic chest trauma
>
> Just a quick request of the lists views.
>
> Case: 55 year old fit and well male falls 4 feet of a ladder onto the
> right
> side of the chest. Presents to A+E with right sided chest pain,
> decreased
> chest expansion and decreased air entry on that side. However, he is
> generally well seen by SHO in A+E and gets an erect AP X-ray.
>
> The film is of good quality and shows a fracture of the 4th rib. There
> is a
> small (5cm) area of surgical emphysema seen on the chest film
> laterally
> which is just palpable clinically. There is also blunting of the
> costophrenic angle - presumably blood. There is no radiographic
> evidence of
> pneumothorax (though there must be one).
>
> He is going to be admitted for observation anyway. The question is
> should
> you put a formal chest drain in this man?? We did not. The decision we
> made
> has been criticised by some of our collegues.
>
> Simon Carley
> Anaesthetics / Intensive Care
> Stepping Hill Hospital
> Stockport
> England
> [log in to unmask]
>
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