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  • • Hemothorax is classified by the amount of blood

    • -Minimal < 350 mL

      -Moderate 350-1500 mL

      -Massive > 1500 mL

    • The rate of bleeding after evacuation of the hemothorax is more important than the initial return of blood on placement of the chest tube

    • Hemothorax should be suspected with penetrating or severe blunt thoracic injury

    • In 85% of cases, tube thoracostomy is all the treatment necessary

    • Pneumothorax occurs with laceration of the lung or chest wall following penetrating or blunt trauma

    • Tension pneumothorax develops when a flap-valve leak allows air to enter the pleural space but not exit

    • Increasing intrapleural pressure interferes with venous return and must be immediately relieved

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Epidemiology

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  • • Trauma patients

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Symptoms and Signs

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  • Hemothorax: Decreased breath sounds, dullness to percussion

    Pneumothorax: Possibly tympany to percussion, decreased breath sounds

    Tension pneumothorax: Tracheal deviation away from affected side, tympany to percussion, decreased breath sounds, hypotension, distended neck veins

    Sucking chest wound: Obvious chest wall defect

    • Hypoxia

    • Dyspnea

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Laboratory Findings

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  • • Hypoxemia

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  • • Mechanism and physical exam often pinpoint problem

    • Underlying and abdominal injuries can often dictate course of therapy

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  • • Physical exam

    • Chest x-ray (upright or semi-upright)

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  • • Initial resuscitation and stabilization

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Surgery

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  • Hemothorax

    • -Tube thoracostomy (chest tube) NOT needle aspiration

      -Thoracotomy or thoracoscopy are rarely indicated

    Pneumothorax: Tube thoracostomy

    Tension pneumothorax: Needle thoracostomy followed by tube thoracostomy

    Sucking chest wound: Occlusive dressing and tube thoracostomy followed by operative reconstruction of chest wall

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Indications

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  • • Initial chest tube output > 1000 mL

    • Chest tube output > 100-200 mL/h

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References

Pape HC et al. Appraisal of early evaluation of chest trauma: development of a standardized scoring system for initial clinical decision-making. J Trauma. 2000;49:496.  [PubMed: 11003329]
Feliciano DV et al. Advances in the diagnosis and treatment of thoracic trauma. Surg Clin North Am. 1999;79:1417.  [PubMed: 10625986]

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