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215 Current management of moderate/severe traumatic pneumothoraces: a survey of emergency clinicians
  1. Edward Carlton1,
  2. Millie Watkins2,
  3. Pascale Avery1
  1. 1North Bristol NHS Trust
  2. 2University of Bristol Medical School

Abstract

Aims/Objectives/Background Traumatic pneumothoraces are present in one-fifth of multiple trauma victims. Traditional teaching mandates the insertion of a chest drain in the majority of cases. However, recent retrospective observational evidence suggests a trend towards conservative management. The aim of this survey was to understand the current emergency medicine (EM) practice in placing chest drains for the management of moderate/severe traumatic pneumothoraces.

Methods/Design This scoping survey was developed through expert consensus. To achieve face validity, clinical sensibility testing was performed using a pilot survey (with user feedback). There were 14 pilot-phase respondents. The survey was then modified to achieve content validity. The survey was sent electronically to senior EM doctors in 15 sites internationally, and involved six clinical/imaging vignettes asking ‘how likely are you to insert an intercostal chest drain to manage the pneumothorax in ED?’. A five-point response was available from very unlikely to very likely. All pneumothroraces were >1 cm on imaging, but mechanism, physiology and need for ventilation varied.

Results/Conclusions Of a potential 409 respondents, 141 responses were received (34% response rate). Respondents had a range of clinical experience, with the majority qualified more than 10 years (median; 19 years).

For 5/6 cases chest drain insertion was likely or very likely in >50% of responses, ranging from 52% for a non-compromised 1 cm pneumothorax in a ventilated patient to 98% for a tension pneumothorax on chest x-ray. Chest drain insertion was unlikely or very unlikely (62% of responses) in one case; an 86-year-old female on rivaroxaban with moderate respiratory compromise (respiratory rate 30 min-1) and a 2 cm pneumothorax.

There is a broad range of clinical practice involving both conservative and invasive strategies in the treatment of moderate/severe traumatic pneumothoraces. There is clinical equipoise for interventional trials to determine the optimal management strategy for this patient group.

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