Two days ago a woman fell from the height of 1,5 m. She complains of severe thoracic pain on the left and dyspnea. Chest X-ray reveals hydropneumothorax on the left with fluid level at the 7th rib and the lung collapsed by 1/3. The 6th-7th ribs are fractured along the scapular line. Serohemorrhagic fluid was obtained during thoracic puncture. What treatment tactics should be chosen?

Answer options

1. Alcohol-novocaine block of the fracture area
2. Intubation of trachea with artificial pulmonary ventilation
3. Thoracocentesis at the 2nd intercostal space
4. Thoracocentesis on the left at the 7th intercostal space
5. Repeated puncture of the pleural cavity

Explanation

The most common cause of massive hemothorax in blunt injury is continuing bleeding from torn intercostal vessels or occasionally from the internal mammary artery secondary to fractures of the ribs. Accumulation of blood in a hemothorax can significantly compromise respiratory efforts, compressing the lung and preventing adequate ventilation. Presentation is with hemorrhagic shock, flat neck veins, unilateral absence of breath sounds, and dullness to percussion. The initial treatment consists of correcting the hypovolemic shock, insertion of an intercostal drain (the 7th intercostal space), and, in some cases, intubation. Initial drainage of more than 1 500 mL of blood or ongoing hemorrhage of more than 200 mL/h over 3–4 hours is considered an indication for urgent thoracotomy. Blood in the pleural space should be removed as completely and rapidly as possible to prevent ongoing bleeding, and empyema, or fibrothorax later. Clamping a chest drain to tamponade a massive hemothorax is not helpful. Bailey & Love’s short practice of surgery. – 27th edition. – P. 368.