Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial

Abstract

BACKGROUND The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH. METHODS We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48–431] mL vs. 88 [35–245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08–1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

Risk Factors for Retained Hemothorax after Trauma: A 10-Years Monocentric Experience from First Level Trauma Center in Italy

“…The literature reports several risk factors of retained hemothorax: high chest AIS score, low hematocrit rate, initial HTX volume (with an increased risk of 15% every 100 mL/day of HTX), low GCS, IOT at admission, number of TT placed, and length of time with thoracostomy [ 6 , 7 , 15 ]. In this study, 41% of patients with HTX on admission developed RH.…”

“…The mortality rate was 6.4%. The median size of HTX was 353 mL (233–397), and, as described by Prakash et al, the development of an RH increased in moderate and large initial HTX with 44.3% and 39.1% RH risk rates, respectively [ 7 ]. To our knowledge, pre-admission physiology data were never investigated so far, and pre-hospital SpO 2 level < 90% seems to be related to increased RH risk.…”

“…To our knowledge, no study analyzed predictors for surgery requirements. The reported rate of RH requiring definitive surgical treatment varies between 28.3 and 54.7% [ 6 , 7 , 15 ]. This study confirms that 15 (39%) of RH patients needed surgical intervention (VATS or thoracotomy).…”

“…A few authors define retained hemothorax (RH) as a residual hematic pleural effusion larger than 500 mL after 72 h of treatment with TT [ 5 ], and its incidence ranges between 17.6% and 28.9% [ 6 , 7 ]. It represents a major source of morbidity as it is associated with an increased risk of empyema, pneumonia, trapped lung, and prolonged hospital stay [ 8 , 9 , 10 ].…”

Okkulter und residueller Hämatothorax nach Thoraxtrauma – Empfehlungen der interdisziplinären Arbeitsgruppe Thoraxtrauma der Sektion NIS der Deutschen Gesellschaft für Unfallchirurgie (DGU) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT)

“…An interdisciplinary task force of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU) on thoracic trauma offers recommendations for post-trauma care of patients with occult and/or retained haemothorax, as based on a comprehensive literature review. Mit zunehmendem Schweregrad der thorakalen Verletzung im AIS (Abbreviated Injury Scale) und einem größeren Volumen des initialen Hämatothorax steigt das Risiko für die Entstehung eines rHT im Verlauf (15 % Steigerung pro 100 ml) [1]. Von klinischer Wichtigkeit ist die Unterscheidung zwischen kompliziertem rHT und unkompliziertem rHT.…”