Simon Carley wrote:
>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.
There seems to be a generally supportive opinion so far about conservative
management here. I think management depends on what problems you might
expect, where they will happen, and on the availability of the right
personnel to manage them.
In a teaching hosital, with a reasonable number of experienced people
available, I believe your management to be entirely appropriate. I would
have made it clear to junior medical and also nursing staff what I was
concerned about, and how they would recognise it, together with what should
be done if it developed.
In a more isolated position, such as a small District General Hospital
where there are only one or two sufficiently experienced people on site
then I think discretion is the better part of valour. A "prophylactic"
drain is warranted.
If the patient is being transferred between hospitals for in-patient care (
as would happen in Hull ) then a drain is mandatory. The back of an
ambulance is not the place to have a tension pneumothorax that might have
been anticipated, and needle decompression by a paramedic, are substandard
treatment for somebody who has been under the care of an Emergency
Department.
Stand your ground on this one at Manchester Royal Infirmary, but there are
caveats for other places.
Darren Walter
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