Hemothorax and Occult Pneumothorax, Management of

Level 1

No recommendations.

Level 2

1. Ultrasound can reliably be used to identify pneumothorax and pleural effusion.
2. CT of the chest is indicated in patients with persistent opacity on chest radiograph after tube thoracostomy to determine whether significant undrained fluid exists.
3. Primary VATS of stable penetrating thoracoabdominal wounds is safe and effective for the diagnosis and man­agement of selected diaphragm and pulmonary injuries.

Level 3

Level 1

Persistent retained hemothorax, seen on plain films, after placement of a thoracostomy tube should be treated with early VATS, not a second chest tube.

Level 2

VATS should be done in the first 3 days to 7 days of hospitalization to decrease the risk of infection and con­version to thoracotomy.

Level 3

1. All hemothoraces, regardless of size, should be considered for drainage.
2. Attempt of initial drainage of hemothorax should be with a tube thoracostomy.
3. Intrapleural thrombolytic may be used to improve drain­age of subacute (6-day to 13-day duration) loculated or exudative collections, particularly patients where risks of thoracotomy are significant. 

Level 1

Level 2

1. Patient physiology should be the primary indications for surgical intervention rather than absolute numbers of ini­tial or persistent output.
2. 1500 mL via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration. 

Level 3

Level 1

Level 2

A persistent air leak on postinjury day 3 should prompt a VATS evaluation.

Level 3

1. Occult pneumothorax, those not seen on chest radiograph, may be observed in a stable patient regardless of positive pressure ventilation.
2. Scoring systems are not accurate in predicting which patients will need a tube thoracostomy for occult pneu­mothorax.