Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma

Nimitt J. Patel, MetroHealth Medical Center, Case Western Reserve University School of Medicine (CWRU), USA. Electronic address: nimitt.patel.md@gmail.com.
Linda Dultz, UT Southwestern School of Medicine, USA. Electronic address: Linda.Dultz@utsouthwestern.edu.
Husayn A. Ladhani, MetroHealth Medical Center, CWRU, USA. Electronic address: husaynladhani@gmail.com.
Daniel C. Cullinane, Maine Medical Center, USA. Electronic address: cullinane.daniel@marshfieldclinic.org.
Eric Klein, Northwell Health, USA. Electronic address: eklein2@northwell.edu.
Allison G. McNickle, UNLV School of Medicine, USA. Electronic address: Allison.McNickle@unlv.edu.
Nikolay Bugaev, Tufts Medical Center, USA. Electronic address: NBugaev@tuftsmedicalcenter.org.
Douglas R. Fraser, UNLV School of Medicine, USA. Electronic address: douglas.fraser@unlv.edu.
Susan Kartiko, George Washington University Hospital, USA. Electronic address: susan.kartiko1@gmail.com.
Chris Dodgion, Medical College of Wisconsin School of Medicine, USA. Electronic address: cdodgion@mcw.edu.
Peter A. Pappas, University of Central Florida College of Medicine, USA. Electronic address: peterpappas52@gmail.com.
Dennis Kim, Harbor-UCLA Medical Center, USA. Electronic address: dennisyongkim@gmail.com.
Sarah Cantrell, Duke University Medical Center Library & Archives, Duke University School of Medicine, USA. Electronic address: sarah.cantrell@duke.edu.
John J. Como, MetroHealth Medical Center, CWRU, USA. Electronic address: jcomo@metrohealth.org.
George Kasotakis, Duke University School of Medicine, USA. Electronic address: george.kasotakis@duke.edu.

Abstract

BACKGROUND: Traumatic hemothorax poses diagnostic and therapeutic challenges both acutely and chronically. A working group of the Eastern Association for the Surgery of Trauma convened to formulate a practice management guideline for traumatic hemothorax. METHODS: We formulated four questions: whether tube thoracostomy vs observation be performed, should pigtail catheter versus thoracostomy tube be placed to drain hemothorax, should thrombolytic therapy be attempted versus immediate thoracoscopic assisted drainage (VATS) in retained hemothorax (rHTX), and should early VATS (≤4 days) versus late VATS (>4 days) be performed? A systematic review was undertaken from articles identified in multiple databases. RESULTS: A total of 6391 articles were identified, 14 were selected for guideline construction. Most articles were retrospective with very low-quality evidence. We performed meta-analysis for some of the outcomes for three of the questions. CONCLUSIONS: For traumatic hemothorax we conditionally recommend pigtail catheters, in hemodynamically stable patients. In patients with rHTX, we conditionally recommend VATS rather than attempting thrombolytic therapy and recommend that it should be performed early (≤4 days).