Chest tube or observe
Howard Berkowitz
hcberkowitz at hotmail.com
Fri Feb 2 04:31:06 GMT 2007
>From: "Ian Seppelt" <SeppelI at wahs.nsw.gov.au>
>Reply-To: "Trauma & Critical Care mailing list"
><trauma-list at trauma.org>
>To: <thoracicsurgpa at msn.com>,
><trauma-list at trauma.org>,<Peter_Clark at wsahs.nsw.gov.au>
>Subject: Re: Chest tube or observe
>Date: Fri, 02 Feb 2007 14:31:11 +1100
>
>Yes, a number of times. These are not patients seen in the acute ward,
>but those who end up in the chronic pain clinic because of severe
>ongoing neuropathic pain due to injury to an intercostal nerve. It's a
>recognised complication of insertion of chest drains, or for that matter
>thoracotomy. I can't quote exact figures but anyone on the list with a
>particular interest in chronic pain will.
Has anyone seen this sort of intercostal neuropathic damage result in not
reasonably constant chronic pain, but an intense exertional pain? I speak
personally here; about 6 months post-CABG, I developed a pain, always
starting at the left acromion and radiating medially into the chest with
continued exertion. I'm in a long-term chest program at NIH, and they are
stumped, although they are reasonably certain it is not anginal, after
research-level invasive testing. No ST changes, no change in cardiac output.
People mutter "chest wall syndrome" and go away grumbling.
Several people have suggested mechanical damage from the thoracotomy,
perhaps with some reduced circulation to the chest, since it can also
sometimes be triggered with an intracardiac catheter, but again with no
objective changes to the fully monitored heart.
>
>A thoracic surgeon I anaesthetise for occasionally has a collection of
>these patients - I have met some of them when they come for their
>periodic intercostal blocks under "sedation" ie two minute propofol GA.
>
>Neuropathic pain as a complication of a procedure is acceptable if the
>procedure was necessary, but is not acceptable if the procedure was not
>indicated in the first place.
>
>Ian
>
> >>> thoracicsurgpa at msn.com 2/02/2007 2:00pm >>>
>Ian
>
>Have you ever encountered "iatrogenic neuropraxia (complex chest wall
>pain syndrome)" from
>a chest tube?? If so, please elaborate.
>
>Thanks in advance.
>
>~doug~
>
>
>
> 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<mailto: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<mailto: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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