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Difficulty: MediumSurgical and Procedural Interventions

A 35-year-old man is brought to the emergency department by emergency medical services following a high-speed motorcycle collision. On arrival, he is confused and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 78/45 mm Hg, pulse is 135/min, and respiratory rate is 28/min. Pulse oximetry shows 88% on room air. Primary survey reveals a patent airway but absent breath sounds over the right hemithorax and dullness to percussion. An extended focused assessment with sonography in trauma (eFAST) scan reveals a large fluid collection in the right pleural space and no pericardial effusion. A right-sided tube thoracostomy is promptly placed, which immediately drains 1,600 mL of bright red blood. The patient's blood pressure transiently improves to 88/50 mm Hg after the administration of 1 liter of intravenous crystalloid fluid, but then drops back to 76/40 mm Hg. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select all that apply)

  1. Transfer to the operating room for an urgent exploratory thoracotomyAnswer
  2. Activation of a massive transfusion protocolAnswer
  3. C
    Computed tomography angiography of the chest to identify the bleeding source
  4. D
    Admission to the surgical intensive care unit for close hemodynamic observation
  5. E
    Administration of intravenous metoprolol to control the patient's tachycardia

Answer

The most appropriate immediate next steps are transferring the patient to the operating room for an urgent exploratory thoracotomy and activating a massive transfusion protocol.
This patient has a massive hemothorax, evidenced by the immediate drainage of 1,600 mL of blood upon tube thoracostomy placement. The standard indications for an urgent exploratory thoracotomy in the setting of a hemothorax include an immediate initial output of greater than 1,500 mL (or 20 mL/kg), continuous bleeding at a rate of greater than 200 mL/hr for 2 to 4 consecutive hours, or persistent hemodynamic instability despite adequate resuscitation. Since this patient meets the absolute criteria for a thoracotomy, he must be transferred immediately to the operating room. Simultaneously, because he is in severe hemorrhagic shock that has not responded to initial crystalloid resuscitation, activation of a massive transfusion protocol is required to provide packed red blood cells, fresh frozen plasma, and platelets, typically in a 1:1:1 ratio, to prevent the lethal triad of trauma (coagulopathy, hypothermia, and acidosis).

Step-by-Step Solution

1
Assess the patient's hemodynamic status and response to initial interventions.
The patient remains in refractory hemorrhagic shock (blood pressure 76/40 mm Hg) despite initial fluid resuscitation and chest tube placement.
Determining hemodynamic stability is the primary branch point in trauma management algorithms.
2
Evaluate the output from the tube thoracostomy.
The chest tube immediately drained 1,600 mL of bright red blood.
Massive hemothorax is defined by an immediate output of >1,500 mL, which is a universally accepted indication for urgent surgical intervention.
3
Determine the definitive management and resuscitation strategy.
The patient requires surgical control of bleeding (thoracotomy) and balanced blood product resuscitation (massive transfusion protocol).
Crystalloid alone is insufficient for massive hemorrhage and causes dilutional coagulopathy, necessitating a 1:1:1 transfusion strategy concurrent with surgical repair.

Key Concept

In patients with a massive hemothorax (defined as >1,500 mL of immediate chest tube output or >200 mL/hr for 2-4 hours), the most appropriate management is urgent exploratory thoracotomy accompanied by activation of a massive transfusion protocol.
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Topics

Surgical and Procedural Interventions

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