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
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In reference to aspiration of simple pneumothoraces, I
note with interest
that the BTS guidelines advocate a trial of needle
aspiration before
resorting to chest drainage in all cases. Has anyone on
the list
successfully avoided insertion of a chest drain in those with
>50%
pneumothoraces, or is it simply delaying the
inevitable?
Ffion Davies
SpR A&E, Mersey
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
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
Very interesting - I too would not have inserted a chest
drain BUT.....
regular frequent observations essential; repeat chest film
at four to six
hours; low threshold for chest drain if any deterioration.
If a careful
EXPERIENCED eye can't be kept on him, the safest thing to do
is to put in a
chest drain prior to admission.
Lawrence
Jaffey
Liverpool
Subject: conservative tx of traumatic chest
trauma
An interesting question Simon.
When I
was posted to a small(ish) rural hospital without an A&E Obs ward
I
seemed to have a run of these.
They did get a chest drain, and I
like to think it was for proper medical
reasons rather than just me
wanting to do something practical.
My justification (and I think it is
right), is that Sods law decrees that
otherwise they will get a tension,
and be seen in the night by a PRHO who
will miss whats happening and
start throwing Ventolin at them because they
are SOB.
If you can
guarantee decent monitoring, and the availability of someone
experienced
to sort it out quickly when it goes bad,then I think
conservative
management is the right thing.
I just feel that in many cases this
council of perfection is unobtainable,
and so conservative management is
a little too risky to feel comfortable
with.
David Roe
A&E
SpR, Mersey
Perfectly reasonable management providing you can trust
the "observation".
Otherwise what is the point of admitting
him? If you cannot trust those
observing they should not be doing
it.
Best wishes,
Rowley Cottingham
>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
Most of these are seen and discharged in A&E, but a few
get as far as the
physicians. I tend to sit on them for a few hours
to make sure they are
clinically stable, then discharge them with strict
advice to return
immediately if dyspnea worsens. For bigger
pneumothoraces, <50% I would
try apsiration first, then consider chest
tube insertion depending on
clinical condition. >50%
pneumothorax mandates tube placement.
Interestingly, in the last
hospital I worked in tubes were supplied without
trochars, in line with
the teaching that one should put them in with
forceps. This seems
to be driven by the surgeons rather than the chest
physicians, and I
suspect it's due to ATLS teaching. Does anyone on the
list have any
opinions as to whether using a plastic introducer is
acceptable?
These are made by Portex, and go in through the proximal drain
hole on
the tube, into its lumen, and out at the distal end. I've
found
they work well, and allow a smaller incision to be used than that
necessary
to admit both tube and forceps.
Andy Johnston
Senior
SHO
General Medicine
Aberdeen Royal Infirmary
AB25 2ZN
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
>Interestingly, in the last hospital I worked in
tubes were supplied without
>trochars, in line with the teaching that
one should put them in with
>forceps. This seems to be driven by
the surgeons rather than the chest
>physicians, and I suspect it's due
to ATLS teaching. Does anyone on the
>list have any opinions as
to whether using a plastic introducer is
>acceptable? These are
made by Portex, and go in through the proximal drain
>hole on the
tube, into its lumen, and out at the distal end. I've
found
>they work well, and allow a smaller incision to be used than
that necessary
>to admit both tube and forceps.
The
important aspect is not necessarily how the actual drain is inserted
but
how the pleura is entered. The use of trocar drains encourages
forceful
insertion through the pleura without control preventing lung
injury. If you
are breaching the pleura first with a blunt technique eg
gloved finger, then
it is perfectly reasonable to use a plastic trocar to
then guide the
subsequent drain in, provided your hole is large enough in
the first place
to allow the drain to enter without
forcing.
Richard Steyn
Cardiothoracic
Surgery
Liverpool
andy johnston wrote:
> >50%
pneumothorax mandates tube placement.
Why?
If the plearal leak has
sealed it self when the lung collapsed half way rather
than one third of
the way what difference does this make to the likelihood of
aspiration
being successful?
Andrew
I couldn't agree more. I have seen several
"complete" spontaneous pneumothoraces
treated successfully by
simple aspiration. It may be necessary to reaspirate once
or even twice,
but I would personally rather that than have a chest drain
inserted.
Lawrence Jaffey
Liverpool
Just a follow up note to let the list know how this chap
got on.
He was admitted for observation to a surgical ward where he
was monitored
with SaO2 monitoring and hourly obs. He had a repeat
examination and CXR at
6 hours (no change) and again the next morning
(still no change). He was
sent home for review in one week with clear
instructions to return if at
all symptomatic. Total time in hospital -
about 36 hours.
Criticism came from several sources - sadly I believe
some of it came from
people who "just fancied a go" at a chest
drain!!
Simon Carley
Anaesthetics / Intensive Care
Stepping
Hill Hospital
Stockport
England
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