Pleural Space Trauma

• • 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

Epidemiology

• • Trauma patients

Symptoms and Signs

• • 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

Laboratory Findings

• • Hypoxemia

• • Mechanism and physical exam often pinpoint problem

  • Underlying and abdominal injuries can often dictate course of therapy

• • Physical exam

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

• • Initial resuscitation and stabilization

Surgery

• • 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

Indications

• • Initial chest tube output > 1000 mL

  • Chest tube output > 100-200 mL/h

References