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Difficulty: MediumCardiothoracic and Vascular Surgery

A 28-year-old man is brought to the emergency department by paramedics after a high-speed motorcycle collision. On arrival, he is in severe respiratory distress and appears pale and diaphoretic. Vital signs are temperature 36.5°C (97.7°F), blood pressure 75/40 mm Hg, pulse 138/min, and respirations 32/min. Physical examination reveals rightward tracheal deviation. The left hemithorax is dull to percussion with absent breath sounds. Intravenous access is established, and a bolus of warmed crystalloid is initiated. A tube thoracostomy is placed in the left fifth intercostal space, which immediately returns 1,600 mL of bright red blood. Over the next 5 minutes, an additional 250 mL of blood drains into the collection unit. A repeat blood pressure is 68/35 mm Hg. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography angiography of the chest
  2. Emergent thoracotomyAnswer
  3. C
    Placement of a second left-sided chest tube
  4. D
    Transthoracic echocardiography
  5. E
    Intravenous administration of broad-spectrum antibiotics

Answer

Emergent thoracotomy is required due to the massive initial blood output (>1,500 mL) indicating major intrathoracic injury.
The correct answer is emergent thoracotomy. This patient presents with a massive hemothorax following blunt thoracic trauma, complicated by severe hemorrhagic shock. A tube thoracostomy is the most appropriate initial step to evacuate the pleural space, re-expand the lung, and quantify the bleeding. However, the immediate evacuation of >1,500 mL of blood (or ongoing hemorrhage of >200 mL/hr for 2 to 4 hours) is a standard absolute indication for an emergent thoracotomy. Such massive bleeding typically originates from systemic vessels or major hilar structures, which require direct surgical hemostasis in the operating room to prevent exsanguination.

Step-by-Step Solution

1
Analyze the patient's presentation and the result of the initial intervention.
The patient is in hemorrhagic shock with a massive left hemothorax, confirmed by the immediate evacuation of 1,600 mL of bright red blood via tube thoracostomy.
Tracheal deviation, dullness to percussion, and absent breath sounds followed by massive blood return establish the diagnosis of a massive hemothorax.
2
Evaluate the indications for urgent surgical intervention.
Immediate return of >1,500 mL of blood is an absolute indication for emergent thoracotomy.
This high volume of acute bleeding typically indicates injury to systemic vessels (e.g., intercostal arteries, internal mammary arteries) or major hilar structures that require direct surgical hemostasis.
3
Assess the patient's hemodynamic stability to rule out imaging or conservative management.
The patient remains in profound shock (blood pressure 68/35 mm Hg) despite initial fluid resuscitation and chest tube placement.
Hemodynamically unstable patients must proceed directly to the operating room; transporting them for cross-sectional imaging (CT) is contraindicated.

Key Concept

Indications for emergent thoracotomy in blunt or penetrating thoracic trauma include initial chest tube drainage of greater than 1,500 mL of blood, or ongoing hemorrhage of greater than 200 mL/hr for 2 to 4 consecutive hours.
Estimated Time:1m 0s
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Topics

Cardiothoracic and Vascular Surgery

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