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Excerpt
I always welcome any opportunity to highlight the need to intervene quickly and decisively in anyone who has a potential for developing a tension pneumothorax. The speed with which a simple pneumothorax can convert to a life-threatening and indeed fatal pneumothorax is still too often unappreciated.
The fact that ventilated patients can tolerate chest wall incisions is not new. All of us who insert chest drains in these circumstances know that as the Spencer-Wells forceps are passed through the pleura, the condition is often resolved and the patient improves dramatically. The chest drain can then be inserted at a more leisurely pace. The purpose of the drain in fact is to keep the track open as if the wound were left as the only means of decompression it would inevitably seal and the condition potentially recur. What these authors have shown is that the interval between surgical decompression and the insertion of a chest drain can be prolonged when there are special circumstances and reinforcing of this well-established observation is most welcome.
Without appearing to be unnecessarily critical, it is of course possible that a pneumothorax was not present in some of these cases as the diagnosis of a nontension pneumothorax without an x-ray film is more difficult than is often appreciated, particularly in the prehospital setting. The residual pneumothorax seen on later x-ray films may in fact have been iatrogenic rather than resolving pathology. However, the lesson to be drawn is that, in ventilated patients, whether or not your diagnosis is correct, it is perfectly safe to proceed and treat the patient as though they had a pneumothorax. The dangers of failing to resolve a traumatic pneumothorax in the prehospital setting far outweigh the potential dangers of unnecessary thoracostomy, and this has been well illustrated in this most welcome paper.
Finally, the authors reiterate well-recognized problems with the use of urine bags in chest drainage. Such problems can be avoided by the use of devices designed to combine the portability of a urine bag with a valve mechanism such as that manufactured by SIMS Portex Limited as part of the ambulatory chest drainage kit.
A. D.
