trauma. It can lead to hypovolemic shock and can significantly reduce vital
capacity if it is not recognized. It is associated with a PTX approximately
25% of the time. Hemorrhage from injured lung parenchyma is the most
common cause of hemothorax, but this tends to be self-limiting unless
there is a major laceration to the parenchyma. Specific vessels are less often
the source of bleeding. A hemothorax is treated with chest thoracostomy
(chest tube)that is generally placed in the fourth or fifth intercostal space
at the anterior or midaxillary line, over the superior portion of the rib. The
tube should be directed superior and posteriorto allow it to drain blood
from the dependent portions of the chest. In an isolated PTX, the tube is
positioned anteriorly to allow it to suction air. Once the tube is inserted, it
is important to closely monitor blood output. Indications for thoracotomy
include:
- Initial chest tube drainage of 1000 to 1500 cc of blood (a and b).
- 200 cc/h of persistent drainage (c).
- Patient remains hypotensive despite adequate blood replacement, and
other sites of blood loss have been ruled out. - Patient decompensates after initial response to resuscitation.
- Increasing hemothorax seen on chest x-ray studies.
162.The answer is c.(Rosen, pp 248-249.)This question addresses the
“C,”circulation, in the ABCs. Initial fluid resuscitation usually begins with
crystalloid fluids such as 0.9% normal saline or Ringer lactate. In general,
if the patient remains hemodynamically unstable after 40 cc/kg of crystal-
loid administration (approximately 2-3 L), then a blood transfusion
should be started. Fully cross-matched blood is preferable; however, this is
generally not available in the early resuscitation period. Therefore, type-
specific blood (type O, Rh-negative or type O, Rh-positive)is a safe
alternative and is usually ready within 5 to 15 minutes. Type O, Rh-negative
blood is typically reserved for women in their childbearing years to prevent
Rh sensitization. Type O, Rh-positive blood can be given to all men and
women beyond their childbearing years.
(a)The patient’s underlying cause of hypotension is hypovolemia sec-
ondary to hemorrhage. Therefore, to treat her hypotension you should treat
the underlying cause. She requires fluid resuscitation with blood and even-
tually may be taken to the OR to stop the bleeding. Epinephrine is used if
the patient is in cardiopulmonary arrest and no longer has a pulse. How-
ever, the underlying cause, hypovolemia, must be corrected. (b)The best
Trauma Answers 173