[size=20px]12-year-old boy crashed his motorbike and fractured ribs 4-8 on the left side. A chest tube was placed in the emergency department for a large hemothorax. On post-trauma day 3, the patient remains tachypneic and has a hemothorax occupying half of the pleural cavity. The tip of the chest tube appears within the hemothorax. The most appropriate management strategy is: ​

 

A ​Turning the patient side-to-side every 3 hours for the next two days

 

B Placement of a second chest tube by Interventional Radiology

 

C Instillation of alteplase (tPA) into the chest once daily for 3 days

 

D Drainage of retained hemothorax via Video-Assisted Thoracoscopic Surgery (VATS)​​[/size]

B

D

correct answer

D Drainage of retained hemothorax via Video-Assisted Thoracoscopic Surgery (VATS)​

 

This patient has a retained hemothorax. Low quality data from adult trauma patients suggest that a small hemothorax that is not symptomatic or associated with a pneumothorax can possibly be observed without drainage.​

 

​This retained hemothorax is large. Adult studies suggest that Video-assisted Thoracoscopic Surgery (VATS) is associated with fewer additional procedures, shorter length of stay, and lower risk of empyema compared thrombolytic therapy. Ideally, VATS should be performed within 4 days of injury.​

 

​A second chest tube or position changes are unlikely to be effective in this scenario.​

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