EM Quick Hits 18 Conservative Management Pneumothorax, Microdosing Buprenorphine, Practical Use of CRITOE, Canadian TIA Score, Pediatric Surviving Sepsis Guidelines, Safety of Peripheral Vasopressors

Topics in this EM Quick Hits podcast

Justin Morgenstern on watchful waiting for large spontaneous pneumothoraces (0:44)

Michelle Klaiman on mirco-dosing buprenorphine for opiate use disorder (5:17)

Arun Sayal on the practical application of CRITOE in pediatric elbow fractures (10:45)

Jeff Perry on The Canadian TIA Score (19:37)

Sarah Reid on updated pediatric surviving sepsis guidelines (25:59)

Salim Rezaie (Best of REBELEM) on safety of vasopressor administration through peripheral IVs (33:40)



Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Michelle Klaiman and Anton Helman

Cite this podcast as: Helman, A. Morgenstern, J. Klaiman, M. Sayal, A. Perry, J, Reid, S. Rezaie, S. EM Quick Hits 18 - Conservative Management Pneumothorax, Microdosing Buprenorphine, Practical Use of CRITOE, Canadian TIA Score, Pediatric Surviving Sepsis Guidelines, Safety of Peripheral Vasopressors. Emergency Medicine Cases. May, 2020. https://emergencymedicinecases.com/em-quick-hits-may-2020/. Accessed [date].

Watchful waiting of large spontaneous pneumothorax



* This multicenter, open label, non-inferiority trial of 316 patients compared small bore chest tube treatment for primary spontaneous pneumothorax >32% (using Collins method - see below) to conservative management (observation for 4 hours followed by repeat chest x-ray and discharge from the ED if walking comfortably and vital signs were stable)

* The primary outcome of complete radiologic resolution of the pneumothorax occurred in 98.5% of the intervention group at 8 weeks and 94.4% of the conservative management group, a "non-inferior" difference and complete resolution of symptoms at 8 weeks was similar ( 93.4% vs 94.6%)

* Secondary outcomes show that pneumothoraces took about 2 weeks longer to resolve in the conservative group, however they had shorter hospital stays, less time of work, less CT scans, less recurrence and less serious adverse events

* Consider including conservative management of spontaneous pneumothorax in shared decision making



NEJM quick video of the trial

The Collins method estimates the size of pneumothorax using a calculation based on measuring the interpleural distance at the apex  (A) and the midpoints of the upper (B) and lower (C) halves of the collapsed lung to the hemithorax on a PA chest x-ray.



Ep 158 Management of Primary Spontaneous Pneumothorax

Expand to view reference list



* Brown SGA, Ball EL, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. The New England journal of medicine. 2020; 382(5):405-415

* First10EM: Conservative treatment for pneumothorax 

* St Emlyn’s JC: Conservative management of pneumothoraces.

* REBEL EM: Spontaneous Pneumothorax: Stand There ...