Management of Massive Hemothorax Requiring Emergent Thoracotomy
In an emergent thoracotomy for massive hemothorax, the priority is to secure the airway first, followed by establishing large-bore IV access, and then proceeding with immediate surgical control of bleeding sources while simultaneously addressing coagulopathy and fluid resuscitation. 1
Initial Approach
1. Airway Management
- Secure the airway via endotracheal intubation as the first priority
- Administer high FiO2 to address hypoxemia
- Protect airway from aspiration of blood
2. Circulation and Access
- Establish large-bore IV access (preferably 8-Fr central access)
- Initiate fluid resuscitation with warmed blood products
- Draw baseline labs:
- Full blood count (FBC)
- Prothrombin time (PT)
- Activated partial thromboplastin time (aPTT)
- Clauss fibrinogen
- Cross-match
3. Immediate Surgical Intervention
- Rapidly evacuate accumulated blood and clots from the thoracic cavity
- Identify and control bleeding sources:
- Direct pressure on bleeding vessels
- Clip ligation of identifiable bleeding vessels
- Electrocautery for smaller bleeding points
- Suture repair of vascular or cardiac injuries if present
Blood Product Resuscitation
- Implement a balanced transfusion strategy:
- Use 1:1:1 ratio of red cells:FFP:platelets for severely traumatized patients 2
- Target a minimum platelet count of 75 × 10^9/L
- Maintain fibrinogen >1 g/L (use fibrinogen concentrate or cryoprecipitate if needed)
- Actively warm all transfused fluids to prevent hypothermia
- Consider cell salvage autotransfusion if available
Management of Coagulopathy
- Anticipate and prevent coagulopathy with early FFP infusion (15 ml/kg) 2
- Monitor for both dilutional and consumptive coagulopathy
- Consider point-of-care testing (TEG/ROTEM) if available for targeted correction
- For established coagulopathy, provide more than 15 ml/kg of FFP
Surgical Techniques
- For active bleeding that cannot be controlled by simple measures:
- Perform direct repair of injured vessels or lung parenchyma
- Consider lobectomy or pneumonectomy for extensive lung injuries
- For cardiac injuries, perform direct suture repair
- Complete evacuation of blood clots is essential to prevent:
- Empyema
- Fibrothorax
- Respiratory compromise
Post-Thoracotomy Management
- Transfer to critical care for continued monitoring
- Continue to monitor coagulation, hemoglobin, and blood gases
- Assess wound drains for ongoing bleeding
- Once bleeding is controlled:
- Normalize blood pressure, acid-base status, and temperature
- Avoid vasopressors
- Continue active warming
- Initiate standard venous thromboprophylaxis as soon as bleeding is controlled 2
Common Pitfalls and Caveats
- Beware of coexisting pericardial laceration which can present as hemothorax rather than cardiac tamponade 3
- Delayed surgical intervention (>7 days) leads to increased operating time, longer drainage periods, and extended hospital stays 4
- For patients with comorbidities (sepsis, diabetes, immunocompromised status), mortality risk is significantly higher 5
- Consider arterial embolization as an adjunct or alternative to surgery in select hemodynamically stable patients 6
Early and aggressive surgical intervention with simultaneous correction of coagulopathy offers the best chance for survival in patients with massive hemothorax requiring emergent thoracotomy.