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Difficulty: MediumSurgical and Procedural Interventions

Paramedics rush a 27-year-old male to the trauma center following a high-speed motorcycle collision. The patient is visibly distressed, confused, and diaphoretic. His temperature is 36.5°C (97.7°F), pulse is 132/min, blood pressure is 84/52 mm Hg, and respiratory rate is 28/min. Pulse oximetry shows 89% on room air. Physical assessment demonstrates leftward tracheal deviation, and breath sounds are absent over the right hemithorax with marked percussion dullness. Intravenous access is rapidly established and volume resuscitation is initiated. A 32-French thoracostomy tube is inserted into the right midaxillary line, yielding an immediate return of 1,600 mL of bright red blood. Over the subsequent 15 minutes, an additional 150 mL drains. The patient's blood pressure remains 82/50 mm Hg despite rapid infusion of 2 L of warmed crystalloid and 1 unit of uncrossmatched packed red blood cells. Which of the following is the most appropriate next step in management?

  1. A
    Helical CT scan of the thorax
  2. B
    Cross-sectional imaging of the abdomen and pelvis
  3. Emergent right-sided thoracotomyAnswer
  4. D
    Initiation of a norepinephrine infusion
  5. E
    Transfer to the intensive care unit for monitoring

Answer

Emergent right-sided thoracotomy
The correct management for this patient is an emergent right-sided thoracotomy. In the setting of blunt or penetrating thoracic trauma, a massive hemothorax is a life-threatening emergency. The classic indications for urgent thoracotomy include an immediate return of >1,500 mL of blood upon tube thoracostomy insertion, or continuous bleeding of >200 mL/hour for 2 to 4 hours. This patient immediately drained 1,600 mL and remains hemodynamically unstable despite aggressive resuscitation with crystalloids and blood products. Immediate surgical exploration is required to identify and ligate the bleeding source, which is often an intercostal artery, internal mammary artery, or major pulmonary vessel.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and physical examination findings.
The patient is in hemorrhagic shock with signs of right-sided pleural fluid (dullness, absent breath sounds) and mediastinal shift.
To identify life-threatening thoracic injuries during the primary trauma survey.
2
Evaluate the output from the tube thoracostomy.
An immediate drainage of 1,600 mL of blood is observed, with continued bleeding.
To determine if massive hemothorax criteria for surgery are met.
3
Determine the indication for surgical intervention.
The massive initial blood output (>1,500 mL) combined with persistent hemodynamic instability dictates emergent surgical exploration.
To achieve definitive hemostatic source control and prevent exsanguination.

Key Concept

Indications for urgent thoracotomy in a patient with a massive hemothorax include an immediate initial chest tube output greater than 1,500 mL or ongoing hemorrhage greater than 200 mL/hour for 2 to 4 hours, particularly in the setting of hemodynamic instability.
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Topics

Surgical and Procedural Interventions

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