Case in the Spotlight 5 answer
1. Describe the CXR
This is a plain CXR of a 29 year old male presenting with sudden onset right sided chest pain and dyspnoea. It is an AP film with appropriate positioning and exposure. There is no unacceptable rotation and the film has been taken at full expiration.
There is evidence of a large right sided pneumothorax. This is suggested by the lack of lung markings in the upper zone and a clear demarcation of the superior lung border at the level of T4. There is no associated tracheal deviation or mediastinal shift, suggesting this is not a tension pneumothorax. Lung fields otherwise appear clear with no evidence of consolidation or abnormal lesions. Costophrenic angles are visible bilaterally with no evidence of effusion or haemothorax. There is no free gas under the diaphragm. The mediastinum appears normal. Cardiac borders are clearly visible and the heart appears normal. There is no evidence of any rib fracture.
There is an additional film taken at full inspiration. The pneumothorax is still visible, and at >2cm would be considered ‘large’ by British Thoracic Society Guidelines.
Move to a monitored bay
Get senior input/opinion
Supportive care - Oxygen/analgesia/explanation
Initial Management as per BTS 2010 guidelines - aspiration of pneumothorax
Definitive care – Intercostal catheter insertion. We will upload a video and some information re this procedure. Observation vs aspiration vs intercostal catheter is an important issue.
Referral – to the surgical registrar. In some hospitals there is a respiratory medical team as first point of referral.
Identify– identify yourself, and ID the patient using three identifiers
Situation – the patient has a moderate size pneumothorax but is stable with no signs of tension
Background – usually well, but a smoker.
Assessment – clinical signs of pneumothorax were confirmed on CXR, have these available but all details probably not needed in the referral
Request – the surgical registrar to attend and assess the patient. You would like to do the intercostal catheter and need supervision please
For information re the outcome:
Immediately post ICC insertion:
ICC in situ 48 hours, 4 hours post ICC removal