Chest tube or observe

[Guy Jackson]

Some more data please.

Why did the EMS team place the chest tube? SOB by itself seems inadequate
indication. Your M&M should review their SOP in detail, most particularly if
the drain was sited only a few minutes from a CXR.

No matter what you do, if you put a hole in the chest you will give the
patient a pneumothorax, no matter what the tool used. This includes needles
(and is a reason against them). In the absence of a pre-procedure CXR (or
USS), the only way you know is by a gush of air if tension is present, and
whether the lung felt deflated (or there was a gap) to the operator. Is the
latter documented?

How was the patient positioned for the initial CXR? The pneumothorax
described can be small if erect. If supine there is more air in there than
you think!

Where was the chest drain on CT? I have all too frequently seen
inexperienced operators push it straight into the oblique fissure, there to
block. This is one of the reasons why the patient can develop a tension
pneumothorax with a drain in situ. The differential diagnosis of your
subsequently enlarging pneumothorax includes blocked drain.

To answer your questions:

1. The question is whether or not you should re-site the drain. If his sats
are OK, and he is not in respiratory distress I would wait for the CT if you
are doing one anyway (but why?). If not, and you think that for whatever
reason the air is not being drained, you should re-site.
2. Why do you wish to re-irradiate the patient in the absence of clinical
signs or symptoms?
3. I do not know any surgeon who would discharge a patient with an
un-drained traumatic pneumothorax.
4. The vast majority of the ' aspirate +/-observe' data is in patients with
spontaneous pneumothoracese. Anybody out there doing this in trauma?

Guy Jackson
London, UK.



----- Original Message ----- 
From: "saad shebrain" <shebrain1 at yahoo.com>
To: <trauma-list at trauma.org>
Sent: Tuesday, January 30, 2007 2:45 PM
Subject: Chest tube or observe


17 yom, driver, seatbelted, involved in a slow T-bone injury while making a
turn.
  at scene, c/o loss of cons for few secs. while en-route to hospital by
EMS, he c/o SOB. EMS team placed drain (Heimlick valve), no gush of air. in
ER c/o left lower ribs tenderness .stable vitals other than Some abrasions
in legs, and nasal lac.
  CXR showed small Apical PTX. 1-1.5cm strip. Was this traumatic from the
accident vs by EMS team???
  the drain was d/cd. CT scan of chest showed small anterior and mediastinal
PTX. no other injuries on CT abd/pelvis.
  pt is sat 100% RA.
  pt was admitted with 100% non-rebreather, CXR F/U (in 4hs no changes in
PTX, in 12hours no changes in PTX, in 16h there is increased PTX to 40-50%).

  few Questions:
  1.Should I put chest tube immediately even if his PTX was 5-10% without
any changes in his sat.
  2.my understanding, pt with blunt trauma to chest, if they do not have PTX
on initial presentation, they should be followed by CXR to r/o occult PTX
that might declare itself.
  3.as this M&M case now, was the initial plan;[ admit, observe, CXR and if
PTX put chest tube] completely wrong?
  4. when can I observe pt with small PTX?


  Thank you
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