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• Patient confidentiality
  C. Andrew Eynon
  Published on: 17 October 2002
• Another modality for detection of pneumothorax
  Stewart S Chan
  Published on: 10 October 2002
• Failure of detection of pneumothorax on chest radiograph
  Matthew J Reed
  Published on: 16 September 2002

• Published on: 17 October 2002

  Patient confidentiality

  • C. Andrew Eynon, Director of Neurosciences Intensive Care

  Dear Editor

  Details contained in a recent paper by Kane and colleagues [1] contained non-clinical information that allowed rapid and easy identification of the patient concerned. This was compounded by inclusion of a figure that had been widely reported in the national press at the time of the accident.

  The maintenance of patient confidentiality is a prerequisite in the publication of case reports. I would...

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  Dear Editor

  Details contained in a recent paper by Kane and colleagues [1] contained non-clinical information that allowed rapid and easy identification of the patient concerned. This was compounded by inclusion of a figure that had been widely reported in the national press at the time of the accident.

  The maintenance of patient confidentiality is a prerequisite in the publication of case reports. I would encourage the editors to reject such articles in future.

  Reference

  (1) Kane TPC, Nuttall MC, Bowyer RC, Patel V. Failure of detection of pneumothorax on initial chest radiograph. Emerg Med J 2001;19:468-469.

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  Conflict of Interest:
  None declared.

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• Published on: 10 October 2002

  Another modality for detection of pneumothorax

  • Stewart S Chan, Adjunct Assistant Professor

  Dear Editor

  I read with interest and agreement over the article by Kane et al.,[1] as well as the eletter response of Reed published on 16 September. For trauma patients requiring mechanical ventilation it is vitally important to diagnose pneumothorax promptly. However these are the conditions (supine anteroposterior films) in which chest radiography is likely to perform not as well. Thoracic CT scan is super...

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  Dear Editor

  I read with interest and agreement over the article by Kane et al.,[1] as well as the eletter response of Reed published on 16 September. For trauma patients requiring mechanical ventilation it is vitally important to diagnose pneumothorax promptly. However these are the conditions (supine anteroposterior films) in which chest radiography is likely to perform not as well. Thoracic CT scan is superior, but more time is required. Another modality for the diagnosis of pneumothorax is ultrasound.

  It has recently been shown that thoracic ultrasound can reliably diagnose pneumothorax, and that surgical residents are able to complete the focused scanning within 2-3 minutes.[2] Hence this modality is faster than radiography or CT scan. Its utility may benefit the trauma patient about to undergo mechanical ventilation, and may be incorporated in the focused abdominal sonography for trauma (FAST) exam. More research in the ultrasound diagnosis of pneumothorax is needed before it can be widely used.

  References

  (1) Kane TP, Nuttall MC, Bowyer RC, and Patel V. Failure of detection of pneumothorax on initial chest radiograph. Emerg Med J 2002;19:468-469.

  (2) Dulchavsky SA, Schwarz KL, Kirkpatrick AW, Billica RD, Williams DR, Diebel LN, Campbell MR, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001;50:201-205.

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  Conflict of Interest:
  None declared.

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• Published on: 16 September 2002

  Failure of detection of pneumothorax on chest radiograph

  • Matthew J Reed, Specialist Registrar in Emergency Medicine

  Dear Editor

  Whilst reading the article by Kane et al.,[1] the case of a recent patient who presented to our department came to mind, that is probably relevant to the discussion regarding the diagnosis of pneumothoraces by CT scan.

  A 44 year old lady car driver presented to A&E after an RTA with a combined impact of 50mph. She complained of neck, sternum and chest pain. On examination she had midli...

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  Dear Editor

  Whilst reading the article by Kane et al.,[1] the case of a recent patient who presented to our department came to mind, that is probably relevant to the discussion regarding the diagnosis of pneumothoraces by CT scan.

  A 44 year old lady car driver presented to A&E after an RTA with a combined impact of 50mph. She complained of neck, sternum and chest pain. On examination she had midline upper cervical spine tenderness, sternal and rib tenderness. X rays showed no fracture however an unusual lytic lesion was noticed at C2 on the plain radiograph. Due to this being unrelated to her trauma and with no other injuries detected, she was discharged home with radiology follow-up, which it was decided after consultation with the radiologists would consist of an MRI and isotope bone scan. All her other plain films were reported as normal at the time by the radiologists.

  5 weeks later an MRI scan showed her C2 abnormality to be a benign congenital defect, however her whole body isotope bone scan revealed healing fractures of the mid body of the sternum, the medial right clavicle and the left fifth rib. Subsequent review of her trauma plain films again showed no suggestion of visible fractures. The rare opportunity to perform a bone scan a while after such an injury clearly demonstrated undisplaced fractures which initial radiography was not sensitive enough to pick up. In the case of our woman this was of no clinical consequence and did not affect her recovery.

  The importance of diagnosing a fracture that is only visible on bone scan is therefore of no relevance except in cases where management and prognosis is greatly affected (i.e. scaphoid fractures). This is true of much of A&E medicine and is the reason why we seek more sensitive markers of myocardial damage and pulmonary embolus, whilst not subjecting all ankle sprains to sensitive MRI scanning. Whilst Bridges et al.[2] showed that 35 of 90 traumatic pneumothoraces were diagnosed only after CT scanning, in only 15 patients was there any change in management as a result, and there is no record of this diagnosis affecting outcome. There are no studies that show that CT diagnosed pneumothoraces are of any clinical relevance or are likely to result in a tension pneumothorax.

  Whilst it may prove to be important to make the diagnosis in a patient who is to undergo ventilation, a patient with an isolated minor chest injury and a small CT diagnosed pneumothorax could present a management dilema in the future. The benefit of diagnosing conditions that may not be of clinical relevance must be demonstrated before the wider use of more sensitive diagnostic tools should be advocated.

  References (1) Kane TP, Nuttall MC, Bowyer RC, and Patel V. Failure of detection of pneumothorax on initial chest radiograph. Emerg Med J 2002;19:468-469.

  (2) Bridges KG et al. CT detection of occult pneumothorax in mulitple trauma patients. Emerg Med J 1993;11:179-186.

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  Conflict of Interest:
  None declared.

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