Case 10 | Why is my chest drain not swinging….?
25 yr old male brought in to ED after an un-witnessed motorbike accident. GCS 6, HR 150, SBP 120/, RR 40, Sats 65% (NRM 15L). Severe facial trauma, gurgling respirations with reduced AE on L side of chest. Ambulance officers decompressed the L chest with a cannula on route (with no improvement in sats). eFast was -ve apart from L pneumothorax.
He is intubated (tube placement clinically confirmed including ETCO2) and a finger thoracostomy followed by chest drain immediately placed on the L side……his sats fail to rise >80%…..the chest drain position is confirmed by a senior clinician as clinically through into the pleural cavity BUT is not swinging (draining or bubbling)…..reassessment there is good R AE & some upper L AE. Clinically a R pneumo was not suspected but a chest drain was set-up on the R.
Well………..the sats rose slowly over 5 minutes to 91%. CXR confirmed the ICC placement correctly BUT showed a large mass in the L thoracic cavity. A R ICC was placed.
CT trauma……showed a massive traumatic diaphragmatic hernia. with the stomach and spleen in the L thoracic cavity. The ICC was in the correct place, however it traversed through the defect in the diaphragm into the abdominal cavity.
Progress / disposition…..the L ICC was pulled back and turned superiorly and began to swing. The patient was stabilised and transferred to a local trauma centre for definitive surgical management.