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Title: Hemothorax Related to Trauma Author: Meyer DM. Thorac Surg Clin 17 (2007) 47–55 Key Points • Chest trauma is a leading cause of traumatic death. • Hemothorax due to chest trauma seldom requires operative intervention, and is usually well managed by tube thoracostomy. • Physical exam in blunt trauma is highly exclusionary for hemothorax, while in penetrating trauma, the physical exam is often misleading. • Chest xray, chest CT, and ultrasound are key diagnostic modalities. • Emergency Department (ED) thoracotomy is associated with a very low survival rate. Clinical Conclusions Tube thoracostomy is the treatment of choice for traumatic hemothorax, although VATS is more effective than placement of a second chest tube for retained hemothorax. The total amount of chest tube bleeding may be more closely correlated with mortality than the hourly rate of bleeding, and large volume of initial chest tube bleeding or continued significant volume bleeding over time are indications for thoracotomy. Section Highlights Demographics • Chest trauma, usually resulting from motor vehicle accidents, is the second most common cause of traumatic death, after head trauma, in the United States.[LoCicero J et al, 1989] • Only about 18% of patients require tube thoracotomy and 2.6% require thoracotomy.[LoCicero J et al, 1989]. • Overall mortality was 9.4%, but about 37% of deaths are due to noncardiothoracic injuries. Over half of deaths occur within 24 hours. .[LoCicero J et al, 1989] • Mortality is predicted by low Glasgow Coma Scale and advanced age (>60 years). • The incidence of hemothorax increases as the number of rib fractures increases [Limen ST et al, 2003] Diagnostic Assessment • Physical Examination o In blunt trauma negative predictive value of auscultation and absence of pain for hemothorax or tenderness was 100% and 99% respectively. The sensitivity was 100% and 57% respectively. [Bokhari F, et al. 2002] o In penetrating chest trauma, negative predictive value was < 91%, and sensitivity of auscultation, pain or tenderness, and tachypnea were 50%, 25% and 32% respectively. [Bokhari F, et al. 2002] Thus, radiography is required in patients with penetrating chest trauma regardless of physical findings. • Focused Assessment with Sonography for Trauma (FAST) • Ultrasonography can detect fluid filled spaces above the diaphragm [Figure 1] more quickly than chest xray [Sisley AC , et al, 1998] and with sensitivity of 92%, specificity of 100%, and negative predictive value of 98% in one study [Brooks A et al, 2004]. • Chest Radiograph o An upright chest xray is the standard and primary diagnostic study [Figure 2]. o Supine chest xray may show layering of the hemothorax in the dependent portion of the pleural space, indicating up to 1000 cc of blood in the pleural space. o Mediastinal shift away from the side of injury can occur with large hemothoraces. • Chest CT High-resolution spiral chest CT allows visualization of small amounts of fluid. Hounsfield units may help characterize the fluid (35-70 U more likely to be hemothorax, <15 U more likely to be a serous effusion). [Figure 3] • Thoracentesis Not usually used in acute trauma, but may be helpful in subacute situations. Management Most chest trauma does not require thoractomy. Drainage of the hemothorax is indicated to prevent empyema and fibrothorax. • Tube Thoracostomy: Recommended placement th th o 32-36 Fr thoracostomy tube, Position in the mid-post axillary line, 6 or 7 intercostal space • Video-Assisted Thoracic Surgery (VATS) [Figure 4][Table 1] for Retained Hemothorax [Meyer DM et al, 1997] o Shorter duration of drainage, shorter hospital stay and lower hospital costs when compared to placement of a second chest tube. o 20% conversion rate to open thoractomy to evacuate clotted hemothorax • Thoractomy o Indications for thoracotomy include drainage of ≥ 1500 cc of blood with initial chest tube placement, > 200 cc/hr drainage for 4 hours, or a combination of drainage and hemodynamic instability or shock. [Karmy-Jones R et al, 2001] o Mortality rates increase with total chest blood loss, which may be more important than hourly rate. o In acute injuries, median sternotomy is generally recommended for better hemodyanamic stability and better access to injuries of the heart and great vessels, and for injuries above the sternal angle. o For penetrating injuries left of the left midclavicular line and below the sternal angle, anterior thoracotomy approach is recommended. o For penetrating injuries to the right of the right parasternal line, median sternotomy is recommended. • Management of Occult Traumatic Hemothoraces A lamellar fluid stripe in the dependent pleural gutter on CT scan of ≥ 1.5 cm (“moderate” effusion) was associated with a 4 -fold greater chance of a drainage procedure. [Bilello JF et al, 2005] • Thrombolytic Infusion Videothorascopy is better than intrapleural streptokinase in reducing need for thoracotomy and duration of hospital stay. [Oguzkaya et al, 2005] Late Complications • Empyema 3 Defined by radiographic findings of a persistent and loculated pleural fluid collection, fever ≥ 38°C, and leukocystosi s (>12,000 cells/mm ), or septic course unexplained by another process. o Rare, but may contribute to respiratory failure in up to 10% of patients after blunt trauma [Watkins JA et al, 2000] o Most do not require thoracotomy, and VATS appears promising o Most often caused by Staphylococcus aureus, followed by anaerobic bacteria. o CT scans are more helpful than chest xrays for diagnosis. o Thoracotomy and decortication has significant morbidity (39%). [Heniford BT et al, 1997] • Use of Presumptive Antibiotics in Tube Thoracostomy [Table 2] o Guidelines [Lukette FA et al, 2000] call for presumptive antibiotic therapy with a first generation cephalosporin for patients undergoing tube thoracostomy after penetrating or blunt chest trauma. Antibiotic should be administered for no longer than 24 hours. Controversies • Sequence of Operative Procedures: Should the abdomen or chest be first? o Up to 44% of combined procedures involve inappropriate sequencing [Asensio JA et al, 2002] • Emergency Department Thoracotomy Guidelines have been developed for emergency department thoracotomies [Asensio J et al, 2001]. A working group concluded that ED thoracotomy should only be performed on those arriving in the ED with vital signs or who have a witnessed arrest, ideally in patients who have penetrating cardiac injuries who arrive shortly after the accident. Summary Hemothorax following trauma is usually managed with a tube thoracostomy. In blunt trauma, underlying injuries, and not bleeding, may be the more life-threatening issue. Retained hemothorax is best handled by early intervention with VATS. The use of prophylactic antibiotics for tube thoracostomy is controversial and antibiotics if used should be discontinued after 24 hours. ED thoractomy is associated with a very low survival rate. 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