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Management of post-traumatic retained hemothorax: A prospective, observational, multicenter AAST study

DuBose, Joseph MD; Inaba, Kenji MD; Demetriades, Demetrios MD, PhD; Scalea, Thomas M. MD; O'Connor, James MD; Menaker, Jay MD; Morales, Carlos MD; Konstantinidis, Agathoklis MD; Shiflett, Anthony MD; Copwood, Ben MDthe AAST Retained Hemothorax Study Group

Journal of Trauma and Acute Care Surgery: January 2012 - Volume 72 - Issue 1 - p 11–24
doi: 10.1097/TA.0b013e318242e368
AAST 2011 Plenary Papers
Editor's Choice

Background: The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy.

Methods: An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 hours of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications.

Results: RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH ≤300 cc (odds ratio [OR], 3.7 [2.0–7.0]; p < 0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6–13.7]; p = 0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2–9.0]; p = 0.023), and volume of RH ≤900 cc (OR, 3.9 [1.4–13.2]; p = 0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4–9.9]; p < 0.001), RH >900 cc (OR, 3.2 [1.4–7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2–4.6]; p = 0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively.

Conclusion: RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.

Level of Evidence: II, prospective comparative study.

From the University of Maryland Medical System/R Adams Cowley Shock Trauma Center (J.J.D., T.M.S., J.O., J.M.), Baltimore, Maryland; Los Angeles County + University of Southern California Hospital (K.I., D.D., A.K.), Los Angeles, California; University of Antioquia (C.M.), Hospital Universitario San Vicente de Paul, Medellin, Colombia; Washington Hospital Center (A.S.), Washington, DC; University Medical Center Brackenridge (B.C.), Austin, Texas.

Submitted: September 2, 2011, Revised: October 22, 2011, Accepted: October 24, 2011.

Presented at the 70th annual meeting of the American Association for the Surgery of Trauma, September 14–17, 2011, Chicago, Illinois.

Address for reprints: Joe DuBose, MD, FACS, Air Force CSTARS–Baltimore, University of Maryland Medical System/R Adams Cowley Shock Trauma, 22 South Greene Street, T5R46, Baltimore, MD 21201; email: jjd3c@yahoo.com.

© 2012 Lippincott Williams & Wilkins, Inc.