Chest Trauma Algorithm
VBMC TRAUMA CARE SERVICES GUIDELINE
Chest Trauma Algorithm
Chest Tube Indications, Antimicrobial Prophylaxis, Placement, Management
and Removal
Indications
Antimicrobial Prophylaxis
Tube Sizing
Hemothorax Management
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
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.