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Difficulty: HardCardiothoracic and Vascular Surgery

Emergency medical services arrive at the trauma bay with a 38-year-old construction worker who sustained a fall from a fourth-story scaffolding. En route, he received 1 liter of intravenous crystalloid. Upon arrival, the patient is obtunded and groaning painfully. Vital signs demonstrate a blood pressure of 78/42 mm Hg, a pulse of 138/min, and a respiratory rate of 28/min. Primary survey reveals profound pallor and diaphoresis. The trachea is midline, and jugular venous distention is absent. Auscultation of the chest demonstrates markedly absent breath sounds over the entire left hemithorax with accompanying dullness to percussion. Heart sounds are distinct and rapid. The pelvis is mechanically stable, and an extended focused assessment with sonography for trauma (eFAST) yields negative results for pericardial and intraperitoneal fluid.

A left-sided tube thoracostomy is rapidly placed, which immediately yields 1,750 mL of bright red blood. Following the administration of two units of uncrossmatched packed red blood cells, his blood pressure marginally improves to 82/48 mm Hg.

Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography angiography of the chest
  2. B
    Placement of a second left-sided tube thoracostomy
  3. Transfer to the operating room for exploratory thoracotomyAnswer
  4. D
    Bedside transesophageal echocardiography
  5. E
    Transfer to the operating room for exploratory laparotomy

Answer

Transfer to the operating room for exploratory thoracotomy
This patient presents with hemorrhagic shock secondary to a massive left hemothorax. The initial management for a hemothorax is a tube thoracostomy, which serves both therapeutic (lung re-expansion, hemorrhage evacuation) and diagnostic (quantifying blood loss) purposes. The absolute indications for an emergent exploratory thoracotomy in the setting of penetrating or blunt chest trauma include: 1) Initial immediate output of >1,500 mL of blood, 2) Continuous output of >200 mL/hour for 2 to 4 hours, or 3) Persistent hemodynamic instability despite adequate resuscitation. Because this patient's initial chest tube output was 1,750 mL, he requires immediate surgical exploration to identify and ligate the bleeding source (commonly intercostal arteries, internal mammary arteries, or pulmonary vessels).

Step-by-Step Solution

1
Analyze the patient's hemodynamic status and primary survey findings.
The patient is in class III/IV hemorrhagic shock (hypotensive, tachycardic, altered mental status) with clinical signs of a massive left hemothorax (absent breath sounds, dullness to percussion).
Establishing the stability of the patient and identifying the primary source of bleeding dictates the immediate trauma resuscitation pathway.
2
Evaluate the response to the initial intervention.
A tube thoracostomy was placed, yielding 1,750 mL of blood immediately, and the patient remains hemodynamically unstable despite blood product administration.
Chest tube output volume is the primary metric used to determine if a hemothorax can be managed conservatively or requires surgical exploration.
3
Apply surgical criteria for massive hemothorax management.
The immediate evacuation of >1,500 mL of blood from the pleural space is an absolute indication for emergent thoracotomy.
This high volume of acute blood loss strongly suggests injury to major intrathoracic systemic vessels (e.g., intercostal or internal mammary arteries) or pulmonary hilar structures, which will not spontaneously thrombose and require surgical hemostasis.

Key Concept

Indications for emergent exploratory thoracotomy in thoracic trauma include an immediate chest tube output of >1,500 mL of blood, or ongoing output of >200 mL/hour for 2 to 4 consecutive hours.
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Topics

Cardiothoracic and Vascular Surgery

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