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Steve This topic appeared in a string of emails in Sept 1996 on the list, and several members admitted to conservative management then ! There are too many messages to copy, but this was the text of one: <<Perfectly reasonable strategy - but better left for departments where there is a stable group of SpR's who give each other a proper handover at shift's end !! My first intro to conservative management was as an orthopaedic SHO when I witnessed my consultant arguing nose-to-nose with a cardiothoracic SR about whether a 2 year old girl with a # humerus and a small PTX with surgical emphysema needed a drain. The consultant won, and she resolved within 36 hours under the caring eyes of the paed ward staff . I always find it amazing how quickly children bounce back to normal activities, even with appalling injuries ! BTW, what does the list think about the practice of aspirating small spontaneous pneumothoraces ? This practice/fad seems endemic amongst physicians in Hong Kong but I think it's unnecessary in most cases. I've treated dozens of these conservatively with careful advice to the patient on activity and when to seek further help, and they have all resolved by 1-2 weeks. Anyone had their fingers burned by doing similar ? Rob Cocks Prof. & Director A&E Medicine Prince of Wales Hospital Hong Kong ---------- From: acad-ae-med-request To: acadae messages Subject: conservative tx of traumatic chest trauma Date: Tuesday, September 10, 1996 11:03AM 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] ---------- From: acad-ae-med-request To: [log in to unmask] Subject: RE: traumatic pneumothoraces Date: Wednesday, February 03, 1999 6:12PM Simon, here's the refs "Traumatic pneumothorax: is a chest drain always necessary? " Johnson,G, J Accid Emerg Med 1996, 13, 173-174. "Traumatic Pnemothorax: a scheme for rapid patient turnover" Knottenbelt J.D. Injury 1990 21, 77-80. Surely someone on this list is already managing these conservatively? We plan to start this but would like to hear from those already doing it.This is the principal value of the list surely - sharing knowledge. Steve Meek > ---------- > From: Simon Carley[SMTP:[log in to unmask]] > Sent: 02 February 1999 16:45 > To: [log in to unmask] > Subject: Re: traumatic pneumothoraces > > Could you post the references (or better still the abstracts)??? > > Thanks, > > Simon > > Simon Carley > SpR in Emergency Medicine > Hope Hospital > Salford > England > [log in to unmask] > -----Original Message----- > From: Meek, Steve <[log in to unmask]> > To: [log in to unmask] <[log in to unmask]> > Date: 02 February 1999 14:43 > Subject: traumatic pneumothoraces > > > >Hello > > > >Do any list members treat small traumatic pneumothoraces expectantly? > >(observe, no chest drain). Graham Johnson and John Knottenbelt's papers > >suggest this is safe but what is missing is how long to observe for - 12 > >hours? The latter's paper from Cape Town suggests chest drains can be > >removed as soon as bubbling stops and x ray shows the lung is inflated... > >any comments? Clearly an obs ward and 24 hour on site middle grade cover > are > >prerequisites > > > >Steve Meek > > > %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%