Thoracotomy Indications for Penetrating Chest Injury Based on Chest Tube Output
For penetrating chest injury, thoracotomy is indicated when the initial chest tube output is 1,000 ml or when there is persistent chest tube output of 200 ml/hr for more than 3 hours. 1
Specific Indications Based on Chest Tube Output
The indications for damage control thoracotomy (DCT) in penetrating chest trauma include:
- Initial drainage volume after closed thoracic drainage > 1000 ml 1
- Drainage volume exceeding 200 ml per hour for more than 3 hours 1
- Patients who have not improved after anti-shock treatment or improved temporarily and then deteriorated rapidly 1
Additional Indications for Emergency Thoracotomy
Beyond chest tube output, other important indications for thoracotomy in penetrating chest trauma include:
- Cardiac arrest or impending cardiac arrest due to penetrating trauma 2
- Pericardial tamponade 1, 2
- Severe tracheal and bronchial injuries 1
- Penetrating cardiac injuries 1, 2
- Location of entrance wound in the upper mediastinum 3
- Blood pressure on admission less than 90 mmHg 3
- Radiographic evidence of retained hemothorax 3
Procedural Approach
When thoracotomy is indicated:
- The left-sided anterolateral thoracotomy approach is generally used as the initial incision 1
- This approach allows exposure of the pericardium, descending aorta, proximal left subclavian arteries, and left hilum 1
- If necessary, the clamshell approach can be used to improve exposure of the pericardium, heart, and anatomical structures of the thoracic inlet 1, 2
Outcome Considerations
The decision for thoracotomy should consider:
- Overall survival rates for penetrating thoracic trauma are around 9-12%, but can be as high as 38% in selected cases 4
- Survival correlates strongly with physiologic status at presentation 2
- Patients in profound shock (BP < 60 mmHg) have approximately 64% survival rate 2
Common Pitfalls and Caveats
- Delay in thoracotomy decision can significantly increase mortality. Research shows the risk of death increases linearly with total chest hemorrhage 5
- While older literature suggested waiting for 800 ml of initial output 3, more recent guidelines recommend intervention at 1000 ml 1
- For blunt trauma, the threshold for thoracotomy is different, with urgent thoracotomy rarely justified based on chest tube output alone 6
- Pericardiocentesis as a bridge to thoracotomy may be considered in cardiac tamponade due to penetrating trauma, but immediate thoracotomy is preferred 1
Based on the most recent and highest quality evidence from the Military Medical Research guidelines, the correct answer to the question is (b) initial chest tube output is 1,000 cc, which warrants immediate thoracotomy in penetrating chest trauma.