A 26-Year-Old Man Who Has Been in a Motor Vehicle Collision

Sara W. Nelson, MD; Daniel M. Lindberg, MD

Disclosures

August 31, 2016

The treatment of traumatic pneumothoraces and hemothoraces depends on the volume of blood or air that has accumulated and on the condition of the patient. Hemodynamically stable patients who are not intubated and have a relatively small pneumothorax (ie, < 1 cm wide) can be placed under observation. A repeat film should be obtained after 4-6 hours; if the pneumothorax is unchanged in size, the patient can continue to be observed without the need for decompression or tube thoracostomy. These patients should always be placed on 100% oxygen to increase the rate of reabsorption of the air in the pleural space.

In unstable patients who, on clinical grounds, are suspected of having a pneumothorax, a needle thoracostomy may be performed to quickly decompress the pleural space. A 14-gauge Angiocath (18-gauge or 20-gauge in an infant) should be placed immediately superior to the rib in the second intercostal space, midclavicular line on the affected side. Once in place, the needle is removed and the Angiocath is secured. A rush of air may be appreciated as the Angiocath enters the pleural space.

Pneumothoraces should preferentially be decompressed either by needle decompression or placement of a tube thoracostomy before the patient is intubated, because positive pressure ventilation exacerbates a pneumothorax; however, definitive management of the airway should never be delayed when indicated. Needle thoracostomy generally necessitates the subsequent placement of a chest tube, but stable patients who do not require a chest tube may be observed. In simple spontaneous pneumothoraces, a 20F or 22F chest tube may be used; however, larger-caliber chest tubes (28F to 40F) should be used in most traumatic pneumothoraces and hemothoraces to ensure adequate drainage of any fluid. Chest tubes are placed in the fourth or fifth intercostal space in the anterior axillary or midaxillary line, and they should be directed posteriorly and toward the apex of the lung.

After the tube is secured, it should be connected to a water seal and vacuum device, and placement should be confirmed by chest radiography. In the case of a hemothorax, immediate drainage of more than 1500-2000 mL (or 20 mL/kg) of blood, or ongoing hemorrhage exceeding 600-1200 mL/6 hours (or > 3 mL/kg/hr) after the initial drainage, constitute the definition of a massive hemothorax and are generally indications for a thoracotomy. Occasionally, placement of an additional chest tube may be necessary to assist in draining of the hemothorax. Additionally, the possibility of a bronchial injury should be considered if a continuing air leak is observed after several chest tubes and an unexpanded lung. In hemothorax, chest tubes should be directed posteriorly and inferiorly to arrive posterior to the diaphragm (as opposed to the placement for a simple pneumothorax).

In this case, the junior emergency medicine resident placed a 14-gauge Angiocath in the second intercostal space, midclavicular line of the left chest. A rush of air was appreciated, and the patient's blood pressure (as previously noted in the case presentation) improved to 95/60 mm Hg. The resident then prepared the left chest and placed a 38F chest tube in the fifth intercostal space, midaxillary line. Immediate drainage of 1600 mL of bloody fluid through the chest tube was noted. Un-crossmatched blood was administered, and the surgical team was consulted for the massive hemothorax. The patient was intubated and transported to the operating room (OR). In the OR, the surgery team performed a thoracotomy, repaired the injured lung parenchyma, and ligated several small arteries that were actively bleeding. The patient was transported to the surgical intensive care unit and extubated the following day. The chest tube was removed 48 hours later, and the patient was discharged on hospital day 4 in stable condition.

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