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Snapshot
  • A 19-year-old male is brought to the emergency department following a gunshot wound to the chest. According to the first responders, the man was found unresponsive and was quickly intubated in the field. A physical examination demonstrates decreased lung sounds on the right field and a thoracostomy is quickly performed. The chest tube immediately drained 1600 mL of reddish fluid.
Introduction
  • Clinical definition
    • rapid accumulation of > 1000mL of blood within the pleural cavity  
    • mostly commonly associated with traumatic injury with involvement of the great or hilar vessels
    • can also occur spontaneously (e.g., malignancy)
  • Epidemiology
    • demographics
      • motor vehicle collisions (MVCs) represent the most common cause of major thoracic injury  
      • about 300,000 cases in the U.S. every year
    • risk factors  
      • penetrating chest trauma (e.g., stab or bullet wounds)
      • motor vehicle accidents
      • malignancy
      • blood clotting disorder
  • Pathogenesis
    • trauma to the thoracic cavity leads to bleeding and subsequent blood pooling in the pleural cavity
      • interferes with normal movement of the lungs by preventing normal expansion of the lungs
    • acute systemic blood loss can lead to compensatory measures (e.g., tachycardia and peripheral vasoconstriction)
  • Associated conditions
    • rib fractures
    • pulmonary contusion
    • pericardial tamponade
    • tracheobronchial injury
    • esophageal injury
    • aortic injury
    • pneumothorax
Presentation
  • Symptoms
    • dyspnea
    • pleuritic chest pain
    • lightheadedness
  • Physical exam 
    • vital sign abnormalities (e.g., hypotension and tachycardia)
    • diminished or absent breath sounds
    • dull lung sounds with percussion  
    • collapsed neck veins
    • cyanosis (if large blood loss)
Studies
  • Diagnostic testing
    • diagnostic approach
      • following initial resuscitation and trauma surveys, patients are often diagnosed clinically by positive physical examination findings and later confirmed via chest radiograph
    • imaging
      • chest radiograph
        • best initial test  
        • allows for evaluation of other conditions associated with blunt or penetrating chest trauma (e.g., aortic dissection)
        • positive finding includes blurring of the costophrenic angle and/or partial/complete opacification of the affected thorax
      • ultrasound (e.g., FAST exam)
        • often part of the initial trauma evaluation but is limited by the operator
        • may be more sensitive than chest radiograph in the identification of pneumothorax and hemothorax
      • chest computed tomography (CT)
        • most sensitive test but is not necessary for the diagnosis  
Differential
  • Tension pneumothorax 
    • distinguishing factor
      • clinical features such as hyperresonnace
      • characteristic imaging findings
  • Flail chest 
    • distinguishing factor
      • will see paradoxical movement of the chest wall
Treatment
  • Management approach
    • initial management consists of stabilization (e.g., oxygen) and fluid resuscitation with close monitoring for early signs of respiratory compromise
    • operative management is dependent on the extent of bleeding  
  • First-line
    • small hemothorax
      •  stabilization and expectant management
    • moderate to large hemothorax
      • drainage of blood via large-bore thoracostomy
      • fluid resuscitation  
    • if > 1500 mL of blood or > 200 mL/hour, hemodynamic instability, or need for repeated blood transfusions
      • emergency thoracotomy or video-associated thoracoscopic surgery (VATS) 
  • Second-line
    • thoracotomy/VATS
      • if continued bleeding or retained blood clots
Complications
  • Empyema
    • more likely to occur if there is retained blood within the pleural cavity
  • Fibrothorax  
    • formation of scar tissue secondary to pleural irritation from retained blood  
  • Atelectasis
  • Pneumonia  
  • Pneumothorax
  • Wound infection
  • Hemorrhagic shock and death
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M2.PL.4799) A 45-year-old male presents to the emergency department by ambulance from a motor vehicle accident. The emergency medical technician states that the patient had been the driver and was hit on the driver’s side while crossing over the intersection. The patient will open his eyes and withdraw from pain and but can only make sounds with no coherent words. The patient’s temperature is 97°F (36.1°C), blood pressure is 98/63 mmHg, pulse is 112/min, and respirations are 24/min with an oxygen saturation of 94% on 15 L/min O2 via a non-rebreather mask. Upon physical exam, you note reduced breath sounds on the left. The patient is stabilized and a chest radiograph is obtained, as shown in Figure A.

What is the most likely pleural fluid finding? Review Topic

QID: 109319
FIGURES:
1

Grossly black

18%

(4/22)

2

Lymphocyte count of > 90% of total WBC

5%

(1/22)

3

Presence of amylase

14%

(3/22)

4

Protein fluid to serum ratio > 0.5

55%

(12/22)

5

Triglycerides > 110 mg/dL

9%

(2/22)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.PL.79) A 24-year-old male is rushed to the emergency department after sustaining several gunshot wounds to the chest. He was found nonresponsive in the field and was intubated en route to the hospital. His vital signs are as follows: temperature is 98.8 deg F (37.1 deg C), blood pressure is 87/52 mmHg, pulse is 120/min, and respirations are 16/min. Physical examination is significant for decreased breath sounds and dullness to percussion over the right lung. A chest radiograph in the emergency department shows a large fluid collection in the right thoracic cavity. After aggressive fluid resuscitation is initiated, an emergent chest-tube was placed in the emergency department. The chest tube puts out 700 cc of frank blood and 300 cc/hr over the next 5 hours. A follow up post-chest tube insertion chest radiograph demonstrates significant residual right hemothorax. Which of the following is the next best step in management of this patient? Review Topic

QID: 106152
1

Clamp the chest tube

0%

(0/0)

2

Place the chest tube to water seal

0%

(0/0)

3

Remove the chest tube

0%

(0/0)

4

Open thoracotomy

0%

(0/0)

5

Tracheostomy

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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