When a Chest Tube Just Isn't Enough

The incidence of developing a hemothorax following severe blunt or penetrating trauma to the chest can be as high as 50-75%.  Patients may present to the trauma team with a wide range of symptoms from being completely asymptomatic to hypovolemic shock.  It is vital during the primary survey to listen to both lung fields carefully during the “breathing” portion of the ABCs.   Patients who develop a hemothorax will have decreased breath sounds and dullness to percussion on the affected side.  Obtaining a portable chest X-ray is a quick and easy way to confirm the diagnosis.  A hemothorax can present differently on a chest X-ray depending on the position of the patient when the film is obtained.  In a patient with the chest X-ray taken in the supine position, a hemothorax will present as a haziness or opacification of the affected lung field.  If the X-ray is taken in the upright position, it will often present with blunting of the costophrenic angle.  This is important to know in order to prevent a missed or retained hemothorax.

            In 85% of cases, placement of a tube thoracostomy will adequately treat a hemothorax.  Careful observation of the chest tube output is critical, as it can help guide the need for further interventions.  Prompt surgical exploration is necessary if any of the following conditions are met:

 

1.        > 1liter output during initial thoracostomy tube placement.

2.       Continued hemorrhage > 200ml for 4 consecutive hours.

3.       Continued hemorrhage > 100ml for 8 consecutive hours.       

 

In the majority of cases prompt surgical exploration is unnecessary.  Once a thoracostomy tube is placed, the patient is admitted to the hospital and monitored for decreasing output.  Daily chest X-rays are obtained to evaluate the effectiveness of chest tube treatment. 

            The majority of hemothoraces are evacuated within 3-4 days.  Patients with considerable output beyond this point should be investigated for retained hemothorax, as this is likely the result of persistent clot within the chest.  In 5-30% of patients, the hemothorax is inadequately evacuated after the initial thoracostomy tube. This can create a significant problem for the trauma team as inadequate evacuation can lead to continued respiratory distress or the development of a fibrothorax.  It is important to prevent fibrothorax development as it can lead to an increased risk of infection and subsequent empyema as well as a trapped lung which can cause respiratory compromise and inadequate ventilation. 

            The trauma team has 3 management options when dealing with a retained hemothorax.  These include the use of fibrinolytics within the thoracic cavity, placing a second chest tube, or performing a video-assisted thoracoscopic (VATS) evacuation.  Fibrinolytics are used widely in the pediatric population, but their use is not well established in adults and are therefore not recommended.  Randomized controlled trials have shown VATS to be more effective and associated with a shorter hospital stay compared to placing a second chest tube.  The success of this intervention is markedly improved with early intervention.  In addition, early intervention is associated with a decreased conversion rate to open.  The longer a hemothorax remains within the lung, the more difficult the operation becomes due to an increased inflammatory response.  Therefore it is important to recognize the presence of a retained hemothorax in order to prevent the development of a fibrothorax or empyema, and optimize the likelihood of successful treatment by performing VATS evacuation early on in its course. 

 

1.  Mowery NT, Gunter OL, Collier BR et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J trauma. 2011 Feb;70(2):510-8.

2.  Morales Uribe CH, Villegas Lanau MI et al. Best timing for thoracosopic evacuation of retained post-traumatic hemothorax. Surg Endosc. 2008;22(1):91-95.

3.  Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. 2004; 78(1): 282-285.

4.  Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective randomized trial. Ann Thorac Surg. 1997;64(5): 1396-1400.

 

by Dr. Marc Ward