A 24-year-old patient had been delivered to a thoracic department with a chest injury, fracture of the IV, V, VI ribs on the right. Plan radiography showed the fluid level in the pleural cavity to be reaching the III rib on the right. Puncture contained blood clots. What is the optimal treatment tactics?

Answer options

1. Medical thoracoscopy
2. Hemostatic therapy
3. Emergency thoracotomy
4. Thoracentesis and thoracostomy
5. Pleural puncture

Explanation

Emergency thoracotomy is indicated as a treatment of hemothorax. 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. In penetrating injury, a variety of viscera, both thoracic and abdominal (with blood leaking through a hole in the diaphragm from the positive pressure abdomen into the negative pressure thorax) may be involved. 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, 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.