1. Rapid Clinical Assesment
- ABCDE Approach
- Monitoring and Oxygenation:
- Put on high flow mask
- Maintain SpO₂ > 95%.
- Place the patient on a cardiac monitor.
- Establish intravenous (IV) access.
2. Identification:
Definition
A massive hemothorax is characterized by one or more of the following criteria:
- Rapid Accumulation of Blood:
- ≥1.5 liters of blood collects rapidly in the pleural space.
- Volume Relative to Total Blood Volume:
- 1/3 of the patient's total blood volume accumulates within the thoracic intrapleural space.
- Continuous Blood Loss:
- Ongoing bleeding of ≥200ml/hour for 2 to 4 hours despite initial management.
Clinical Presentation
Suspect a massive hemothorax in a trauma patient exhibiting:
- Respiratory distress
- Reduced or absent air entry on the affected side
- Dullness to percussion over the affected area
- Tracheal position is usually central, but in severe cases, it may be mildly pushed to the contralateral side due to mediastinal shift.
- Collapsed neck veins due to hypovolemia.
- Signs of shock
- Penetrating or blunt trauma chest wall injury.
eFAST Findings:
Hypoechoic (Dark) Collection Above the Diaphragm:
- Presence of Spine Sign
- Absence of Curtain Sign
3. Management and Intervention
Aims to restore:
- Respiratory function
- Circulatory volume
- Controlling hemorrhage.
A. Hemostatic Resuscitation
i. Establish vascular access:
- Insert two large-bore intravenous cannulas (14–16 gauge)
iii. Activate massive transfusion protocol
B. Thoracic Decompression and Pleural Drainage
i. Chest Tube Insertion (Tube Thoracostomy):
- Use a large-bore chest tube (36–40 French)
- Inserted into the fifth intercostal space at the anterior or mid-axillary line.
ii. Monitoring Output:
- Ongoing blood loss of ≥200 mL/hr over 2–4 hours indicates the need for surgical intervention.
C. Urgent Thoracotomy
Indications:
- Initial drainage of ≥1,500 mL of blood upon chest tube insertion.
- Persistent bleeding of ≥200 mL/hr for 2–4 hours.
- Hemodynamic instability despite resuscitation.