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Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions

Dennis, Bradley M. MD; Gondek, Stephen P. MD, MPH; Guyer, Richard A. PhD; Hamblin, Susan E. PharmD; Gunter, Oliver L. MD, MPH; Guillamondegui, Oscar D. MD, MPH

Journal of Trauma and Acute Care Surgery: April 2017 - Volume 82 - Issue 4 - p 728–732
doi: 10.1097/TA.0000000000001370
WTA 2016 Plenary Paper

BACKGROUND Concerted management of the traumatic hemothorax is ill-defined. Surgical management of specific hemothoraces may be beneficial. A comprehensive strategy to delineate appropriate patients for additional procedures does not exist. We developed an evidence-based algorithm for hemothorax management. We hypothesize that the use of this algorithm will decrease additional interventions.

METHODS A pre-/post-study was performed on all patients admitted to our trauma service with traumatic hemothorax from August 2010 to September 2013. An evidence-based management algorithm was initiated for the management of retained hemothoraces. Patients with length of stay (LOS) less than 24 hours or admitted during an implementation phase were excluded. Study data included age, Injury Severity Score, Abbreviated Injury Scale chest, mechanism of injury, ventilator days, intensive care unit (ICU) LOS, total hospital LOS, and interventions required. Our primary outcome was number of patients requiring more than 1 intervention. Secondary outcomes were empyema rate, number of patients requiring specific additional interventions, 28-day ventilator-free days, 28-day ICU-free days, hospital LOS, all-cause 6-month readmission rate. Standard statistical analysis was performed for all data.

RESULTS Six hundred forty-two patients (326 pre and 316 post) met the study criteria. There were no demographic differences in either group. The number of patients requiring more than 1 intervention was significantly reduced (49 pre vs. 28 post, p = 0.02). Number of patients requiring VATS decreased (27 pre vs. 10 post, p < 0.01). Number of catheters placed by interventional radiology increased (2 pre vs. 10 post, p = 0.02). Intrapleural thrombolytic use, open thoracotomy, empyema, and 6-month readmission rates were unchanged. The “post” group more ventilator-free days (median, 23.9 vs. 22.5, p = 0.04), but ICU and hospital LOS were unchanged.

CONCLUSION Using an evidence-based hemothorax algorithm reduced the number of patients requiring additional interventions without increasing complication rates. Defined criteria for surgical intervention allows for more appropriate utilization of resources.

Level of Evidence Therapeutic study, level IV.

From the Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center (B.M.D., S.P.G., R.A.G., S.E.H., O.L.G., O.D.G.), Nashville, Tennessee.

Submitted: February 18, 2016, Revised: December 9, 2016, Accepted: December 14, 2016, Published online: January 18, 2017.

This article was presented at the 46th annual meeting of the Western Trauma Association, February 28–March 4, 2016, in Lake Tahoe, California.

Address for reprints: Bradley M. Dennis, MD, 1211 21st Ave. South, 404 Medical Arts Building, Nashville, TN 37212; email:

© 2017 Lippincott Williams & Wilkins, Inc.