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Difficulty: MediumSurgical and Procedural Interventions

A 28-year-old man is brought to the trauma bay via helicopter following a high-speed motorcycle collision where he was thrown approximately 30 feet. Upon arrival, he is pale and diaphoretic. His blood pressure is 82/50 mm Hg, pulse is 135/min, and respirations are 32/min. Oxygen saturation is 89% on 15 L/min via a non-rebreather mask. Physical examination reveals a midline trachea, absent breath sounds over the right hemithorax, and dullness to percussion on the right side. Large-bore intravenous access is established, and a massive transfusion protocol is initiated. A 36-French right-sided tube thoracostomy is performed, yielding an immediate return of 1,650 mL of gross blood. Five minutes later, an additional 200 mL of blood drains into the collection system, and the patient's blood pressure remains 84/52 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

  1. Transfer to the operating room for an emergent thoracotomyAnswer
  2. B
    Computed tomography angiography of the chest
  3. C
    Continued observation in the emergency department with ongoing transfusion
  4. D
    Immediate admission to the surgical intensive care unit
  5. E
    Placement of a second right-sided tube thoracostomy

Answer

Transfer to the operating room for an emergent thoracotomy
The correct answer is to proceed with an emergent thoracotomy. This patient presents with hemorrhagic shock and a massive hemothorax following severe blunt chest trauma. The initial tube thoracostomy yielded 1,650 mL of blood. The universally accepted indications for urgent or emergent exploratory thoracotomy following chest tube placement include an initial evacuation of >1,500 mL of blood, ongoing output of >200 mL/hr for 2 to 4 hours, or persistent hemodynamic instability despite adequate resuscitation. This magnitude of bleeding typically originates from systemic or hilar vessels and requires direct surgical hemostasis.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and physical examination findings.
The patient is in hemorrhagic shock (hypotensive, tachycardic) with signs of a massive right-sided pleural effusion (absent breath sounds, dullness to percussion).
Initial trauma evaluation identifies life-threatening injuries requiring immediate intervention.
2
Evaluate the results of the initial procedural intervention.
Tube thoracostomy yields 1,650 mL of blood immediately, with ongoing bleeding and persistent hemodynamic instability.
Chest tube placement is both diagnostic and therapeutic for hemothorax, but the output volume dictates the subsequent management pathway.
3
Apply the indications for operative intervention in hemothorax.
The patient meets the criteria for emergent thoracotomy (>1,500 mL initial output).
Massive initial bleeding indicates major vessel or cardiac injury that cannot be managed with a chest tube and transfusion alone.

Key Concept

Indications for emergent thoracotomy in the setting of a massive hemothorax include an initial tube thoracostomy output of greater than 1,500 mL, or ongoing bleeding of 200 mL/hr for 2 to 4 consecutive hours, particularly in hemodynamically unstable patients.
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Topics

Surgical and Procedural Interventions

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