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Difficulty: EasyCardiothoracic and Vascular Surgery

A 25-year-old man is brought to the emergency department via ambulance after sustaining a stab wound to the right side of his chest. He appears pale and lethargic. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 80/50 mmHg, heart rate of 130/min, and respiratory rate of 24/min. Physical examination reveals a single 2-cm laceration in the right fifth intercostal space at the midaxillary line. Breath sounds are markedly diminished on the right side, and dullness to percussion is present. After placing large-bore intravenous access and initiating fluid resuscitation, a right-sided tube thoracostomy is rapidly performed. The chest tube yields an immediate return of 1,600 mL of bright red blood. Which of the following is the most appropriate next step in management?

  1. Emergent exploratory thoracotomyAnswer
  2. B
    Computed tomography of the chest
  3. C
    Observation and administration of packed red blood cells
  4. D
    Administration of intravenous sodium bicarbonate
  5. E
    Initiation of broad-spectrum intravenous antibiotics

Answer

Emergent exploratory thoracotomy
The most appropriate next step in management is an emergent exploratory thoracotomy. This patient has sustained penetrating chest trauma resulting in a massive hemothorax. According to standard Advanced Trauma Life Support (ATLS) guidelines, an immediate return of greater than 1,500 mL of blood upon chest tube insertion is an absolute indication for an emergent thoracotomy. Another indication is ongoing continuous bleeding of greater than 200 mL/hr for 2 to 4 consecutive hours. Surgery is required to identify and definitively control the source of the severe intrathoracic hemorrhage, which typically involves a laceration to a major pulmonary vessel, the heart, or a systemic artery (such as the intercostal or internal mammary arteries).

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status and presenting signs.
The patient is in hemorrhagic shock (hypotension, tachycardia) following penetrating chest trauma.
To recognize life-threatening instability that dictates the urgency of interventions.
2
Assess the immediate output from the tube thoracostomy.
The chest tube yields an immediate return of 1,600 mL of blood.
To determine if established criteria for urgent surgical intervention have been met.
3
Apply standard trauma resuscitation guidelines for massive hemothorax.
Because the initial chest tube output exceeds 1,500 mL, the patient requires immediate surgical exploration.
To achieve definitive hemostasis of likely major pulmonary or systemic vascular injury.

Key Concept

In the setting of penetrating chest trauma, an immediate return of > 1,500 mL of blood upon chest tube insertion, or ongoing bleeding of > 200 mL/hr for 2 to 4 hours, is an absolute indication for an emergent exploratory thoracotomy.
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Topics

Cardiothoracic and Vascular Surgery

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