Scenario 1

A 110 kg, 30-year-old male has fallen off his horse whilst riding after lunch. His injuries identified on completion of the primary survey are:

Click on the images to enlarge.

Fig 1: # 4-8th left ribs complicated by a small pneumothorax and moderate haemothorax	Fig 2: Open # tibia/fibula

Consider two reasons why a chest drain might be indicated in this patient.

Two reasons why a chest drain might be indicated in this patient are the need to:

• Drain the haemothorax, then quantify and monitor further blood loss. In general, a chest drain is indicated if a haemothorax is sufficiently large to be seen on chest x-ray
• Avoid tension of existing pneumothorax, given planned intermittent positive pressure ventilation (IPPV) for lower leg fracture

Does he need the chest drain inserted while he is in the ED?

Not necessarily. If he remains stable, the procedure will be easier and better tolerated by the patient once he is anaesthetised in the anaesthetic room. Negotiate with your anaesthetic colleague. Chest drain insertion in the ED is advisable if surgery is not planned in the next 4 hours.

Learning bite

A chest drain is indicated if a haemothorax is sufficiently large to be seen on the chest x-ray.