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Clinical Case 108: Planes, Drains and Pneumothoraces

Another case inspired by a Twitter debate today.

A Tweet Case was put forward by @FlyingDrBen  (Ben Darwent) who is based in Perth WA – home of LITFL. My friends Minh le Cong, Karim Brohi and Tim Leeuwenburg started a discussion around the case.  Fair to say it got way too big for twitter!  So I am posting this case to get you all thinking and source expertise on the topic.  Here we go…

Rodknee is a 27 yo. man who has presented to a remote hospital following an “incident” in which his girlfriend stabbed him in the right lateral chest with a small kitchen knife ( ~ 12 cm blade).  She apparently found out he had been sleeping with his wife despite his assurances to the contrary.  The oldest story in the book!

Rodknee is a stoic individual and managed to sober up and have a sleep before presenting to the ED about 3 hours after the injury.  There was not much blood loss at the scene and he managed to patch things up with his +1 in the meantime.

On arrival his Obs are all normal ( P = 70, BP = 125/80, RR 14, SpO2 = 99% RA, he is well perfused and alert.  He does complain of some pleuritic pain on inspiration over the site of the wound.  On inspection he has a very neat stab wound ~ 2cm long at the anterior axillary line – 6th intercostal space.  There wis no active bleeding or bubbling.

The attending Doctor is a semi-retired GP from an affluent Sydney suburb who is doing a few locums “for fun” to round out his career.  He has asked for your advice – fortunately you have a High-def VC link up to their ED which is about 250 km away.   So you have a virtual look at the patient.  He is as advertised.

Being an ultrasound enthusiast – you talk the locum through a FAST scan and look for a pneumothorax / haemothorax.  The very rough and ready images reveal a tiny right pleural fluid collection (less than a centimetre) and no clear pneumothorax – although it is hard to exclude in a mobile vertical patient who is 250 km away!  So we think he has a small haemothorax and either no pneumothorax – or a very small pneumo we have not been able to find on US.  He remains haemodynamically stable.

The locum is super keen to get Rodknee transferred out to your bigger ED ASAP – he is the solo cover and has been up all night already.  Fair call – lets get the aeromedical team in to swoop and run.  But……   what about the potential pneumothorax?  Does it need a drain before we put this chap on a small plane?  The textbook says it will expand and might cause tension effect if it does.

Just out of interest – you ask the locum if he is comfortable with placing an ICC if required…  he tells you that he last did one in 1979.  Then he starts waving a metal trocar around like the Swedish chef from the Muppets!  Hmmm, maybe not so soon!

So here is the question – is it better to perform a prophylactic intercostal catheter in a well lit ED under sterile conditions, OR should we fly him without an ICC.  What is the risk of his developing a tension pneumothorax or becoming hypoxic is his possible pneumo expands?

Is a drain mandatory for a 30 minute flight in a small aircraft that will be going to altitude?

Controversial!  Lets hear your thoughts.

Casey

Here is a nice physiology experiment from the Journ of Trauma & Acute Surgery Nov 2014 – small pneumothoraces did expand – but not with any clinical implications at cabin pressure up there.

 

Comments

  1. Ron Cassano says:

    Hi Casey
    Interesting intellectual exercise, but really, do you know of any Australian retrieval service (when not engaged in a war zone), who would transport this man without a drain??
    There is a real risk he would deteriorate in flight, and the retrieval service certainly wouldn’t take that risk. From the history he may also go through alcohol (or other) withdrawal, an added issue in flight. At the other end he will undoubtedly have a CT chest/abdo as we’ve all seen abdominal injuries with these injuries; lastly I’m sure our friendly Locum could be talked through putting in a drain (just like we do with interns on their first go), if there was deterioration prior to the arrival of the retrieval team

  2. A drain is unlikely to be necessary for a flight of that duration. The if the retrieval aircraft has a much greater fuel endurance, even without refueling, it can probably fly the return trip at low[er] altitudes. It would be most appropriate to discuss the possibility of a reduced altitude flight with the retrieval service’s pilot.

  3. Conventional option would be to insert a drain, but on a quick search, I can’t find much actual evidence. This article (Flying with a pneumothorax: a model of altitude limitations due to gas expansion -- http://www.ingentaconnect.com/content/asma/asem/2013/00000084/00000008/art00010) suggests a small pneumothorax may not be so much of an issue as thought.

  4. there are several issues to be clear on here. This is a common retrieval issue and its important to convey what is commonly done.

    When I first started aeromedical retrieval, these cases were managed with prophylactic chest drains. Some services would still do this but things have .changed? Why? One word = ultrasound. We can now use portable USS preflight and even during flight to assess for pneumothorax. This has reduced the number of prophylactic chest drains now which is a good thing!

    Now the major concern is that a small pneumothorax on the ground may expand sufficiently at altitude to compromise the patient. So it doesnt really matter if the pt looks stable on the ground. The issue is if you can reliably diagnose a pneumothorax or not . If the retrieval team or loca doctor can rule out a pneumothorax or at least a big enough one to be seen on USS, then its fine to not insert a drain and be prepared to decompress inflight.

    A lot of folks rely upon going sea level cabin altitude in pressurised cabins, saying this will stop any expansion. Whilst technically this is true, its clear from experience that patients with pneumothorax can still tension, despite being at ground or sea level. Some dispute if this entity does exist..the tension pneumothorax in the spontaneously breathing patient..let me declare my own witnessing of this phenomenon. it is not common but it does occur!

    So in this case, if the local GP as well as the retrieval Team can rule out a big pneumothorax on the ground, preflight then taking them without a chest drain is ok,

    Some folks argue if its a short flight then thats safer. This is illogical. how short is short ? Whilst a short flight generally means only a low altitude is achieved, that does mean less gas expansion, its logical to assume patients with traumatic pneumothoraces can still tension despite the time.

    Notably I recall seeing a young man post MVA 2 days prior who developed crunchy skin over his left shoulder and increasing dyspnoea. He had a large pneumothorax on CXR and yes he got a chest drain preflight!

  5. There’s this paper from Darren Braude et al who describe transport of patients with PTX and no chest drain
    https://www.researchgate.net/publication/264050459_Air_Transport_of_Patients_with_Pneumothorax_Is_Tube_Thoracostomy_Required_Before_Flight

    What worries me most here is the rural foctor waving the ICC around like a muppet! Seriously people, if you are going to work in the bush, then need to make sure have the skills -- critical illness doesnt respect geography! We can teach cheat drain insertion on ATLS-EMST or even better on ETMcourse.com -- and whilst it is great to have locum relief, it behoves both clinicians and the workforce agencies/hospitals to ensure that the locums have the skills

    However, if I landed at this patient I would take control of the ICC and make a decision myself. I dont want to cause an unnecessary ICC or risk empyema through doing in rushe or unsterile circumstances. Then again, I dont want to risk decompensation in flight with all the risks that entails (not least, which side is the PTX and can I access that sid of the chest in an aircraft -- may be impossible if up against the fuselage and patient secured with arms across chest!!

    Ive done lots of tubes. Id place one in this guy most likely, under strict asepsis. Whether flight is 20 mins ot 2 hours is immaterial -- if he goes off in flight I cant stop the aircraft and go back.

    From memory Braudes paper showed you’d get away with NOT placing a tube in 95% of cases. Is it OK to accept a 5% risk of respiratory embarrassment in the back of an aircraft and limited options.

    So -- no muppetry from the Swedishcef locum, but a proper assessment and Rx from the attendng retrieval clinician….

    ..land for the record, I would take pilots advice on whether to fly back at ground level, not sea level (ground is usually higher than sea level!)

  6. Agree with comments above. Very hard to quantify risk.
    Issues for me are:
    1) ICC insertion is not a benign procedure. If the patient is stable and the locum is not credentialled for the procedure -- obviously wait for the retrieval team. If patient deteriorates & it becomes an emergency, then risk/benefit ratio swings in favour of supervised (via video/Skype/phone) decompression/ICC insertion, assuming kit is available.
    2) Risk of deterioration in flight: real risk is unknown. It is a real phenomenon. Also, like Minh I have seen severe clinical tension in a spontaneously breathing patient, leading to peri-arrest situation. Is risk lowered by pressurised cabin (can’t do in chopper)/lower altitude flight? Theoretically yes. Factors such as aircraft type, weather (which may affect altitude), flight duration, availability of US, accessibility of affected side of chest and ability to decompress in flight all need to be weighed up by the retrieval doc.

    If in doubt, a formal, lateral decompression with finger sweep to ensure pleural penetration, and 28Fr ICC would be preferable to a needle decompression/anterior pneumocath in-flight.

    Needles/pneumocaths just as dangerous, if not more so than formal ICC, with risk of false +ves (from subcut emphysema, or lung penetration, or vessel/cardiac penetration), or just failure (buried in pec muscles). See: http://www.smme.org.mx/assets/descompresionpleuraltrauma.pdf

    Any other retrieval people out there who can comment?

  7. Unlike other aspects of his anatomy for this patient, size doesn’t matter. Traumatic PTx + flight, equals tube for transport.

    Interesting and amusing to read the Sept 2014 EMRAP podcast notes about pneumothoraces, (as you know chaired by your born- in- Oz Mel Herbert, blessed be he) which says ‘no flight for ten days, take out all tubes and Heimlich valves yadda yadda yadda. Advice that applies perhaps to Disneyland/SeinfeldLand where Mel now lives and works, cannot apply to Broome et al.

    Just like EMRAP advice (glory to the honored source nevertheless) saying no point treating group A Strep because rheumatic fever Just Doesn’t Happen. Not my experience in Indigenous Australia, probably not yours.

    Broome Docs is the beetroot in my burger, EMRAP v v good, but without Broome Docs its not the same. Thank you all.

  8. The duration of the flight is not relevant to the expansion due to lowered cabin pressure. It is relevant in that the pneumothorax (if any) can grow over time.
    Any pilot can tell you, blocked sinuses hurt more during a brief flight (rapid change in altitude) than a long one.
    Can this GP do a finger thoracostomy? Make the hole, poke a finger in (sterile) and decompress, then leave nothing in the hole.
    100% oxygen can reduce the size (or rapidity of growth) of the pneumothorax, as it allows nitrogen to be reabsorbed. How much of a difference this makes depends on the size of the pneumothorax.
    All up, who is transporting the patient? At worst, the retrieval team can do the drain.
    I agree with Tim: Same as the flight time, rural docs (working for a long or short time) need to be able to do basic things like chest drains.

Trackbacks

  1. […] We covered the pneumothorax / Airplane transfer debate a while back in Clinical Case 108. […]

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