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Fri Sep 26 00:49:37 BST 2008

I share Mark's concerns. People forget the morbidity of chest drains -
an empyema or an intercostal neuopathy can be a catastrophe for a
patient. 

As a simple rule, put in a chest drain if there is a problem on the
Chest X ray. If the CXR is fine but there is an anterior pneumothorax on
the CT leave it alone. Think about the days before total body CT
scanning - a lot of these people would have been anaesthetised without
anyone knowing about the pneumothorax, and very few came to any harm.

I criticise junior surgeons at the trauma M&M for wanting to harpoon
every small pneumothorax.

Cheers, Ian

correspondence to: seppelt at med.usyd.edu.au

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

>>> trauma at emergencyunit.com 09/20/08 8:05 am >>>
Yes, I will, especially if nitrous oxide may be used. I commonly see a
normal(ish) chest film without any evidence of a pneumothorax and then a
large obvious but ANTERIOR air collection on CT. Remember - air rises!

Best Wishes,

Rowley. 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of MARK FORREST
Sent: 16 September 2008 23:17
To: Trauma &amp; Critical Care mailing list
Subject: Re:Anaesthesia - how big a pneumothorax before you site a
drain pre-op?

A real bug bear of mine is colleagues who insist on putting a chest
drain inevery casualty with even the slightest pneumothorax, who is
going to theatre for an anaesthetic.

When I sat my Fellowship, many moons ago, any suggestion of anaesthesia
in such patientswithout a chest drain was a reason for a re-sit next
time!

So what about current views? How big can that pneumo be on the chest
film before you would electively drain before anaesthesia.....does it
depend on IPPV vs spontaneous, use of N2O or air or what are your
criteria??

If you can get reliable access to the chest in theatre would you just
sit tight and observe, whilst they fix the ankle or other minor trauma?

Comments?
Mark F 
UK

----- Original Message ----
From: Robert Waddell II <bobwaddell at bresnan.net>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Tuesday, 16 September, 2008 8:11:16 PM
Subject: Re: Needle Decompression

Thanks Tim, I'll try to get the paper. Your comments have a greater 
volume than some may see in that the classic signs, especially those 
listed in most of the text, include deviated trachea. I believe it 
was Lee in the 80's who showed through a large post evaluation 
analysis that tracheal deviation occurred in non-viable (dead) 
patients and was an extremely late sign and demonstrated that looking 
for the deviation wasted time and aided in the practitioner loosing 
focus of the treatable injuries. Maybe it is time for main stream EMS 
to re-think the "why we do what we do" and get back to a stronger 
focus on the patient we're caring for and their positive outcomes. 
Thanks again.

Take care,

Bob
bobwaddell at bresnan.net 
307 920 2020

On Sep 16, 2008, at 12:53 PM, Coats Tim - Professor of Emergency 
Medicine wrote:

>
> Several posts on this thread have mentioned the 'classic' signs of 
> tension pneumothorax. However there is a very good paper from the 
> Emergency Medicine Journal in 2005 that should make you rethink and 
> question. See:
>
> Leigh-Smith S, Harris T. Tension pneumothoraxtime for a rethink?
> EMJ 2005;22:816.
>
> What SImon and Tim showed was that 'classic' signs of tension 
> pneumothorax are based on operative experience in an anaesthetised 
> patient, where compensatory mechanisms have been reduced. In the non-

> anaesthetised patient there may be a number of compensatory 
> mechanisms which means that the 'classic' signs may well not be 
> present. My experience is that in a non-anaesthetised patient the 
> 'classic' signs of tension pneumothorax only occur periarrest.
>
> On the issue of 'does field needle thorocostomy work?' my experience

> is yes, but only very occasionally. It is certainly not as important

> an intervention as some prehospital trauma courses make out.
>
> Tim Coats.
> Professor of Emergency Medicine.
> Leicester University, UK.
>
>
>
> -----Original Message-----
> From: McSwain, Norman E Jr. [mailto:nmcswai at tulane.edu] 
> Sent: Tue 9/16/2008 4:14 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Needle Decompression
>
> See my comments from the two previous postings this morning. I would
> only add that I have used it several times in the field myself with
> apparent success. I say apparent because there were no radiographs
to
> prove a anatomical pathophysiological improvement. General
improvement
> in the patient's condition that made me believe that something had 
> been
> accomplished by it
>
> Norman
>
> Norman McSwain Jr, MD FACS
> Trauma Director Charity Hospital
> Professor of Surgery
> Tulane University School of Medicine
> 504 988 5111
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of kmattox at aol.com

> Sent: Tuesday, September 16, 2008 9:23 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: Re: Needle Decompression
>
> I for one have never been impressed, nor seen real benefit from
needle
> decompression of the chest.
>
> K
>
>
>
> ------Original Message------
> From: Dr Ross Hofmeyr
> Sender: trauma-list-bounces at trauma.org 
> To: 'Trauma &amp; Critical Care mailing list'
> ReplyTo: Trauma &amp; Critical Care mailing list
> Sent: Sep 16, 2008 9:04 AM
> Subject: RE: Needle Decompression
>
>> You put
>> in in for proper indications ( decreased breath sounds,
>> decreased oxygenation) then is doing its job allowing the
>> lung to expand (blood or air they both can compress the
>> lung).
>
> *Screeches to halt*
>
> Holdonamminit - how, pray tell, does a cannula in the chest help the
> lung
> expand? Do you mean a cannula PLUS non-return valve of some form?
>
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Anaesthesia - how big a pneumothorax before you site a drain pre-op?