Chest tube or observe

[Ian Seppelt]

No place for a chest drain in a small pneumothorax which is only
detected on CT, not clinically or on CXR. Even in a ventilated patient.
Even for anaesthesia (so I'm a bit more hard line than you, Peter). Just
avoid nitrous oxide and remain 'aware' - if the patient goes off you
know exactly what the problem is and what to do about it.

In years gone by, before mindless CT scanning of everything that moved,
there must have been plenty of patients with unrecognised little
pneumothoraces and very few got into any sort of trouble.

Hard to convince junior surgical trainees of that, or of how horrible
an iatrogenic neuropraxia (complex chest wall pain syndrome) or
iatrogenic empyema can be.

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> Peter_Clark at wsahs.nsw.gov.au 1/02/2007 4:38pm >>>

Excellent question. Lets make it harder - you see no pneumo on CXR but
is visible on CT and patient is on a ventilator (IPPV) with contusion
on
CT head.
Should you put a drain in with complications associated with it which
are often forgotten?
 
In general we have not put a drain in if patients stays in ICU and is
closely observed for changes in airway pressure, resp deterioration in
RR or oxygenation or ABG, change in CXR. 
If pneumo gets bigger obviously needs a drain. If goes to OR/Angio
etc.
and access to chest is problem prophylactic drain needed.
 
Interested what others think
 
P

>>> shebrain1 at yahoo.com 31/01/2007 1:45 am >>>
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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