0071643192.pdf

TREATMENT

■ Large-bore chest tube (36–40Fr): Smaller chest tubes will clot.
■ Massive hemothorax is defined as an initial output of >1500 mL of blood.
■ Initial chest tube output of >1200–1500 mL (>20 mL/kg) or persistent
output of >200 mL/hour (>7 mL/kg/hour) or 600 mL/6 hours indicates
need for thoracotomy.
■ Persistent hypotension in the setting of hemothorax is also an indication for sur-
gical intervention even if chest tube output does not cross the above threshold.
■ Consider autotransfusion in the setting of massive hemothorax, but be
wary of contamination from occult GI injury.

COMPLICATIONS

■ Undrained or insufficiently drained blood from the pleural space can get
infected or can cause late pleural fibrosis limiting lung expansion. Get the
blood out.
■ Chest tubes can also introduce infection into the chest: Meticulous sterile
technique should be used.
■ Left lung opacification may be due to traumatic diaphragmatic hernia or
right main-stem intubationwith left lung collapse.
■ Shift of the mediastinum away from the opacification and the presence of
an NG tube going and staying below the diaphragm support the diagnosis
of hemothorax.

Rib Fractures

SYMPTOMS/EXAM

Posttrauma chest pain

DIAGNOSIS

■ Assume rib fractures in any chest trauma patient with localized pain and
tenderness over the ribs or pain with deep inspiration, even if not seen on
CXR.
■ >50% of rib fractures are not evident on CXR.
■ Most common chest injury in adults (usually ribs 4–9)

TREATMENT

■ Consider admission for pain control (opioids, rib block, epidural) and for
observation/workup for other injuries, especially in individuals >50 years
old, smokers, and those with multiple rib fractures.
■ All patients need to maintain lung volumes (ie, 10 deep breaths every
hour while awake) to prevent atelectasis and pneumonia.

COMPLICATIONS

■ First and second rib fractures require a lot of force and are associated with
other significant injuries and with poor outcomes in 15–30% of cases. These
fractures can be associated with vascular, bronchial, and myocardial injuries.
■ Two or more rib fractures are associated with higher incidence of internal
injuries. These patients are also at higher risk for fat emboli and aspiration
pneumonitis (from diminished cough), which can take 24–48 hours to
elucidate on CXR.
■ If a hypotensive patient has fractures of ribs 9–11 consider liver and/or
spleen injuries.

TRAUMA

In patients with traumatic

hemothorax, initial chest tube

output of > 1500 mL or

subsequent output of >200

mL/hour are indications for

operative repair.

Pediatric bony structures are

more pliable than adults. As a

result, children are less likely

to have fractures but more

likely to have underlying

contusion/injury following

blunt trauma.

Consider admission in

patients with multiple rib

fractures or with single rib

fractures and age > 50 years

or underlying lung disease.

The greater the number of rib

fractures, the greater the

morbidity and mortality.