The case:
A motorcyclist is minding his own business, stationary at a set of lights and is rear-ended by a car at ~60-70km/h. He is thrown 10 meters or so from his bike and lands on his left side. Remarkably he is systemically well, except for significant left lateral chest wall pain !!
You think he has reduced air-entry on the left side, but is he’s not dyspnoeic, nor hypoxic. The remainder of his primary survey is unremarkable.
This is his supine CXR…
EFAST showed no evidence of free intraperitoneal fluid, but this is what I saw on the chest….
CT-Chest is performed….
Now, what to do ?
I read a similar case by @keeweedoc … “Conservatism Fails” and found myself looking for evidence. I believe the following paper adequately challenges the old dogma that ‘traumatic pneumothoraces mandate tube thoracostomy’ and empowers us to safely observe the patient with blunt traumatic occult pneumothorax.
The paper:
Moore, FO et al. J Trauma. 2011 May;70(5):1019-23; discussion 1023-5.
Prospective, observation, multicenter study.
Comparison between ‘successfully observed’ & ‘those who failed observation’ for blunt traumatic occult pneumothorax.
588 OPTXs (79% initially observed, 21% received immediate tube thoracostomy)
Only 27 of 448 OPTXs failed observation.
Factors associated with failure of observation.
- Respiratory distress (OR ~6)
- Positive pressure ventilation
- Initial size of OPTX
- Progression of PTX on CXR (OR ~70 !!)
- Associated haemothorax
Interestingly; pulmonary contusion and increasing no. of rib fractures was not associated with failure. PPV to facilitate surgery alone, was also not predictive of failure. No patient in this study developed tension PTX in the observation group.
The case continues…
He is admitted under the trauma surgeons and his pain well controlled on a fentanyl PCA.
Whilst they initially elect to observe his PTX, 4-5 hours later he becomes more dyspnoeic & is found to have worsening subcutaneous emphysema…..
I’m interested to know if this changes your practice ??
Chris.
Andre (@keeweedoc) says
September 26, 2012 at 11:14 amHey Chris,
Been chatting about this a bit here with the recent case. few points.
Failure of observation is pretty rare ~6% in that study.
The indications for a tube make sense:
Big PXT or Haemopneumo or resp distress/PPV use.
We are quite conservative with these here, only further consideration is difference in morbidity between conservative and active treatment?
cpartyka says
September 26, 2012 at 11:40 amHey Andre,
Thats a good question. The authors quote previous studies in which there was no morbidity difference between the observed and intervened groups (low patient numbers though).
In this paper, they only quote 4 (out of 27) patients who sustained complications following ‘failure of observation’, being malposition of tube needing repositioning, 2x recurrent PTXs & one empyema. You can imagine that occurring in either group though and its hard to link this to causality…
If it was me, I’d take my chances and see how I go –> take the drain once my lung declared itself 🙂