Development of a tension pneumothorax despite intercostal dr
The present case has been reported in BMJ.

A 21-year-old man presented to a trauma department with two sucking stab wounds on each side of his posterior thorax. The patient was in respiratory distress with oxygen saturation of 91% on 15 L O2. Blood pressure was 105/72 mm Hg, pulse 112/min and blood gas analysis demonstrated a mixed metabolic and respiratory acidosis.

A left haemopneumothorax was detected clinically although there was no evidence of tension. The stab wounds were covered with damp, three-sided dressings and an intercostal drain (ICD) was inserted into the left hemithorax, draining ∼500 ml of blood.

A radiograph confirmed correct ICD placement but also showed a right-sided pneumothorax. Another ICD was therefore inserted and a radiograph was obtained to check location. The authors were surprised to see enlargement of the pneumothorax and significant left shift of the mediastinum suggesting the development of a right tension pneumothorax.

Learning points
• Posteroinferior placement of intercostal drains allows drainage of any dependent fluid and air, as the latter will distribute evenly throughout the pleural cavity.

• It is possible for tension pneumothorax to develop even in the presence of a correctly inserted, functioning intercostal drain.

• If a pneumothorax persists with a drain in situ, consider failure of the drain or the presence of an on-going air-leak—either internally or externally.

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