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.
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.