A 19-Year-Old Shooting Victim With Complications

Janice Verham, MD


July 08, 2019

Retained hemothorax (a residual hemothorax despite tube thoracostomy placement) has been reported in as many as 17% of patients.[17] A retained hemothorax increases the risk for empyema, as well as prolonging hospital stay and increasing hospital charges.[18,19]

The management of retained hemothorax includes observation, second chest tube placement, intrapleural fibrinolytic therapy, and video-assisted thoracoscopic surgery (VATS). Observation is more likely to be successful if the retained hemothorax is < 300 mL.[20] Placement of a second chest tube may be beneficial in the presence of a poorly placed initial tube thoracostomy; however, surgical intervention with VATS within 5-7 days after the initial injury decreases conversion to open surgery, empyema formation, and length of hospital stay.[21]

Although fibrinolytic therapy is another option, its disadvantages include prolonged hospital stay for the administration of fibrinolysis (3-7 days of infusion). VATS has been shown to decrease the risk for empyema, reduce hospital stay, and decrease the need for open surgery compared with fibrinolytic therapy.[22] A longer duration between development of hemothorax and VATS increases the need for conversion to thoracotomy and prolongs hospitalization, which may be indicated regardless, especially for difficult empyema evacuation or decortication.[23] In the setting of massive hemothorax or ongoing bleeding, open thoracotomy is the procedure of choice.[24] During surgery, bleeding can be controlled at the source, and the hemothorax can be evacuated.

The most feared complications associated with chest tube placement are reexpansion pulmonary edema and vagus nerve irritation. Reexpansion pulmonary edema can have a mortality rate as high as 20%.[24] Although the exact cause is unclear, reexpansion pulmonary edema is thought to be due to sudden and excessive endothelial permeability in the ipsilateral lung.[25] Another severe complication, vagus nerve irritation, has been known to cause sudden death via excess parasympathetic stimulation and bradycardia that causes a fatal arrhythmia.[26,27]

Although these complications may cause a physician to hesitate in placing a chest tube, waiting to place one is also associated with risks. By delaying placement of a thoracostomy tube or incompletely evacuating a hemothorax, a fibrothorax may develop, which effectively "traps" the lung and prevents full expansion.


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