Indications
Tube Sizing
Hemothorax Management (2 Parts)
On retained hemothorax:
Hemothorax is a common finding after both penetrating and blunt trauma to the chest, and is seen in as many as 300,000 cases per year in the U.S.1 Initial treatment of a traumatic hemothorax (HTX) should be drainage by chest tube. All HTXs, regardless of size, should be considered for drainage.2 Emergent thoracotomy should be considered when hemorrhage is large volume (> 1-1.5L) or ongoing (>200cc/hr). Despite intervention, 20% of drained traumatic HTXs will develop a retained component.1 Retained hemothorax (RH) is an independent risk factor for development of empyema, which occurs in as many as 30% of patients with RH.1,3 Therefore, early identification and treatment of RH is imperative.
On CXR, signs suggestive of fluid (vs contusion or other parenchymal lesions) include blunting of the costophrenic angle and layering effects over or under the parenchyma. However, CXR is inadequate to guide decision-making and may in fact provide incorrect information up to 50% of cases.2,4 Therefore, CT chest is indicated in patients with a persistent pleural opacity on CXR after chest tube for traumatic HTX.2
If CT scan shows RH following chest tube placement, estimate volume of the RH. ( V = D2 x L, where D = greatest depth (in cm) of the fluid measured from the parenchyma to the posterior chest wall on the axial images, and L = greatest length of the fluid (in cm) in the cranio-caudal direction as measured on the sagittal images.5
Pleural fluid with a volume <300cc is unlikely to create any noticeable changes on CXR2, ismore likely to go undiagnosed, and is of uncertain significance.3 Patients with RH >300cc should be considered for intrapleural TPA/dornase/streptokinase or VATS/thoracotomy.
Placement of a second chest tube is discouraged. RH 72 hours after initial chest tube placement VATS led to significantly shorter duration of chest tube therapy, shorter hospital length of stay after second intervention, and overall lower hospital costs compared to a second chest tube. Furthermore, > 40% of the patients who had a chest tube placed as a second intervention had to undergo a third intervention.6 2,3
Use of intrapleural fibrinolytics for empyema and parapneumonic effusions has been reported to significantly reduce the need for surgical drainage. However, Level 1 evidence does not exist to support their use in RH, though several groups have reported success using this strategy. Oguzkaya, et al, performed a limited retrospective review of VATS vs intrapleural streptokinase, and found better response, lower complication rate, shorter hospital stay and decreased need for thoracotomy in the VATS group.7 Therefore, VATS remains superior to both second chest tube and intrapleural fibrinolytic therapy for RH. Intrapleural fibrinolytic therapy can be considered second line, for use when, at the discretion of the trauma team, the risks of surgery are felt to be too great.2,3
Optimal timing of VATS relative to patient admission and/or time of RH diagnosis remains undefined. The 2011 AAST RH study group was unable to demonstrate any association between timing of VATS and success rate.3 However, the EAST Practice Management Guidelines recommend that VATS be done within the first 3-7 days of the patient’s hospitalization to decrease the risk of infection and conversion to thoracotomy.2
References on Retained Hemothorax
1.) Dennis BM, Gondek SP, Guyer RA, Hamblin SE, Gunter OL, Guillamondegui OD. Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma Acute Care Surg. 2017;82:728-732
2.) Mowery NT, Gunter OL, Collier BR, Diaz JJ, Haut E, Hildreth A, Holevar M, Mayberry J, Streib E. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011;70:510-518
3.) DuBose J, Inaba K, Demetriades D, Scalea TM, O’Connor J, Menaker J, Morales C, Konstantinidis A, Shiflett A, Copwood B. Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. J Trauma. 2012;72:11-22
4.) Velmahos GC, Demetriades D, Chan L, Tatevossian R, Cornwell EE, Yassa N, Murray JA, Asensio JA, Berne TV. Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient. J Trauma. 1999;46:65-70
5.) Mergo PJ, Helmberger T, Didovic J, Cernigliaro J, Ros PR, Staab EV. New formula for quantification of pleural effusions from computed tomography. J Thoracic Imaging. 1999;14:122-125
6.) Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial. Ann Thorac Surg. 1997;64:1396-1400
7.) Oguzkaya F, Akcali Y, Bilgin M. Videothoracoscopy versus intrapleural streptokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases. Injury, Int J Care Injured. 2005;36:526-529
Management and Removal
References
Sources Used for Guidelines:
Chest Tube Insertion: Patient Preparation Guideline:
1.) Imaging Guideline adapted from information from UpToDate:
Legome, Eric. (2022). Initial evaluation and management of blunt thoracic
trauma in adults. Moreira, M., Khurana, B., and Ganetsky, M. (Eds.),
UpToDate. Available from
https://www.uptodate.com/contents/initial-evaluation-and-management-of-bl
unt-thoracic-trauma-in-adults/print?search=cardiac%20contusion&source=s
earch_result&selectedTitle=3~35&usage_type=default&display_rank=3.
2.) Prophylactic Antibiotics Guideline adapted from UpToDate:
Huggins, J.T., Carr, S.R., and Woodward, G.A. (2021). Thoracostomy tubes
and catheters: Placement techniques and complications. Wolfson, A.B.,
Stack, A.M., Bulger, E.M., Broaddus, C.V., and Vallières E. (Eds.), UpToDate.
Available from
https://www.uptodate.com/contents/thoracostomy-tubes-and-catheters-pla
cement-techniques-and-complications#H3324371931
3.) Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
4.) Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for
antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73.
Chest Tube Sizing for Adults Guideline:
1. Huggins, J.T., Carr, S.R., and Woodward, G.A. (2022). Thoracostomy tubes
and catheters: Indications and tube selection in adults and children.
Wolfson, A.B., Stack A.M., Bulger, E.M., Broaddus, C.V., Vallières E, and
Collins, K.A. (Eds.), UpToDate. Available from
https://www.uptodate.com/contents/thoracostomy-tubes-and-catheters-indi
cations-and-tube-selection-in-adults-and-children/print.
2. Madbak, F. M., & Martin, M. (Comoderators). (2020, Jan 8). All About
Hemothorax: Does Chest Tube Size Matter? (No. 127). [Audio podcast
episode]. In Traumacast. EAST - The Eastern Association for the Surgery of
Trauma.
https://www.east.org/education-career-development/online-education/traum
acasts/detail/1202/all-about-hemothorax-does-chest-tube-size-matter.
Pneumothorax Guideline:
1. de Moya, Marc MD; Brasel, Karen J. MPH, MD; Brown, Carlos V.R. MD;
Hartwell, Jennifer L. MD; Inaba, Kenji MD; Ley, Eric J. MD; Moore, Ernest E.
MD; Peck, Kimberly A. MD; Rizzo, Anne G. MD; Rosen, Nelson G. MD;
Sperry, Jason MPH, MD; Weinberg, Jordan A. MD; Martin, Matthew J. MD
Evaluation and management of traumatic pneumothorax: A Western
Trauma Association critical decisions algorithm, Journal of Trauma and
Acute Care Surgery: January 2022 - Volume 92 - Issue 1 - p 103-107 doi:
10.1097/TA.0000000000003411.
Hemothorax Guideline:
1. Dennis, B., Hamblin, S., and Davis, B. (2021). Hemothorax Guidelines.
Vanderbilt University Medical Center Division of Trauma and Surgical
Critical Care.
https://www.vumc.org/trauma-and-scc/sites/default/files/public_files/Protoc
ols/HTX%20guideline%202021%20update.pdf.
2. Madbak, F. M. & Martin, M. (Comoderators). (2020, Jan 8). All About
Hemothorax: Does Chest Tube Size Matter? (No. 127). [Audio podcast
episode]. In Traumacast. EAST - The Eastern Association for the Surgery of
Trauma.
https://www.east.org/education-career-development/online-education/traum
acasts/detail/1202/all-about-hemothorax-does-chest-tube-size-matter.
3. de Moya, M. (2022). Traumatic Hemothorax. Western Trauma Association.
https://www.westerntrauma.org/wp-content/uploads/2021/03/b21435d708c8
497f9a77cf92125c319b1.pdf
Chest Tube Insertion: Chest Tube Indication Guideline
1.) Water Seal Citation:
Porcel J. M. (2018). Chest Tube Drainage of the Pleural Space: A Concise
Review for Pulmonologists. Tuberculosis and respiratory diseases, 81(2),
106–115. https://doi.org/10.4046/trd.2017.0107
2.) VATS Citation:
Dennis, B., Hamblin, S., and Davis, B. (2021). Hemothorax Guidelines.
Vanderbilt University Medical Center Division of Trauma and Surgical
Critical Care.
https://www.vumc.org/trauma-and-scc/sites/default/files/public_files/Protoc
ols/HTX%20guideline%202021%20update.pdf.
3.) VATS Citation for “Air or Air+Fluid” Category:
Dugan, K. C., Laxmanan, B., Murgu, S., & Hogarth, D. K. (2017).
Management of Persistent Air Leaks. Chest, 152(2), 417–423.
https://doi.org/10.1016/j.chest.2017.02.020.
4.) Chest Tube Removal Adapted from UpToDate:
Huggins, J.T., Carr, S.R., Woodward G.A. (2021). Thoracostomy tubes and
catheters: Management and removal. Wolfson, A.B., Stack, A.M., Bulger,
E.M., Broaddus, and Vallières E. (Eds.), UpToDate. Available from
https://www.uptodate.com/contents/thoracostomy-tubes-and-catheters-ma
nagement-and-removal?search=chest%20tube%20&source=search_result&
selectedTitle=3~150&usage_type=default&display_rank=3#H4149691133.
Published 12/26/18 (S Priest/H Berdel/J Judge/A Bernard); Revised 2-12-24 (C Reynolds/A Bernard)
