What are the indications for placing a chest tube in a patient with traumatic hemothorax and lung contusion?

Indications for Chest Tube Placement in Traumatic Hemothorax and Lung Contusions

For traumatic hemothorax, chest tube placement is indicated when patients present with chest pain, shortness of breath, signs of shock, or attenuated breath sounds on the injured side; the drainage tube should be inserted in the fourth/fifth intercostal space in the midaxillary line using a 16-22 Fr tube for stable patients or 24-28 Fr for unstable patients. 1

Primary Indications for Chest Tube in Traumatic Hemothorax

Massive Hemothorax

• Chest tube thoracostomy is mandatory when patients with thoracic injury present with chest pain, shortness of breath, signs of shock, and attenuated or absent breath sounds on the side of injury. 1
• The diagnosis can be confirmed using B-mode ultrasound in emergency settings when available. 1
• When shortness of breath persists without remission after needle thoracentesis, massive hemothorax should be strongly considered and tube thoracostomy performed immediately. 1

Clinical Instability

• Any clinically unstable patient with hemothorax requires immediate chest tube placement regardless of the volume of blood present. 2
• Clinical instability is defined as: respiratory rate >24 breaths/min, heart rate outside 60-120 beats/min, abnormal blood pressure, room air oxygen saturation <90%, or inability to speak in whole sentences between breaths. 3

Volume-Based Criteria

• Surgical exploration by VATS or thoracotomy becomes necessary if >1,500 mL of blood has been evacuated initially and/or ongoing blood loss exceeds 200 mL per hour. 4
• Initial drainage exceeding 1,000 mL or persistent bleeding >200 mL/hour for 3+ hours warrants immediate surgical consultation. 2

Tube Size Selection Algorithm

For Stable Patients

• Use 16-22 Fr chest tubes for hemodynamically stable patients with traumatic hemothorax. 1, 2
• Small-bore tubes (≤20 Fr) have demonstrated effectiveness and safety in chest trauma, with tube-related complications occurring in only 7.8% of cases. 5
• A 16 Fr tube is sufficient for managing hemothorax that develops more than 24 hours after injury. 6

For Unstable Patients

• Use 24-28 Fr chest tubes for hemodynamically unstable patients or those requiring mechanical ventilation. 3, 7
• Larger tubes (16-28 Fr) are preferred for acute traumatic hemothorax to reduce the risk of clot obstruction. 3

Technical Considerations

• Tubes larger than 28 Fr are generally unnecessary for pneumothorax management and do not improve outcomes. 3, 7
• The risk of additional tube placement, residual hemothorax, and tube occlusion does not significantly increase with tubes <28 Fr compared to 28 Fr tubes. 8

Special Considerations for Lung Contusions

Flail Chest with Pulmonary Contusion

• When patients with thoracic injury present with multiple rib fractures, rapid breathing, and shock, flail chest combined with pulmonary contusion should be considered first. 1
• Paradoxical movement of the chest wall is of great diagnostic significance for flail chest. 1
• Adequate tissue perfusion should be ensured without fluid limitation initially; however, once patients are fully resuscitated, unnecessary fluid should be avoided to prevent worsening pulmonary contusion. 1
• Pain control is critical to reduce the possibility of respiratory failure in patients with flail chest and pulmonary contusion. 1

Hemopneumothorax Management

• For combined hemothorax and pneumothorax, the drainage tube should still be placed in the fourth/fifth intercostal space in the midaxillary line to address both pathologies. 1
• If there is no accompanying hemothorax in pure pneumothorax cases, the drainage tube can be inserted into the second and third intercostal space. 1

Insertion Technique and Safety

Procedural Approach

• Use an incisional approach for chest tube insertion; never use a trocar, as trocar insertion significantly increases the risk of catastrophic organ injury, iatrogenic hemothorax, and pulmonary laceration. 3
• Obtain a post-procedure chest radiograph to confirm tube position and lung re-expansion. 3

Drainage System Configuration

• Connect all chest tubes to a water-seal drainage system with or without suction (-20 cm H₂O). 3
• Apply suction until 24-hour output falls below 150 mL. 3

Antibiotic Prophylaxis

• Administer antibiotic prophylaxis prior to tube thoracostomy in trauma patients to reduce the risk of empyema, with coverage for Staphylococcus aureus. 2
• Continue prophylaxis for 24 hours in trauma patients. 4

Critical Pitfalls to Avoid

• Never clamp a bubbling chest tube, as this can convert a simple pneumothorax into a life-threatening tension pneumothorax. 3
• Do not "milk" or manually squeeze the chest tube, as this practice is not supported by evidence and may cause complications. 3
• Avoid breaching sterility to aspirate clots or mechanically clear obstructions. 3
• Do not reflexively place chest tubes for minimal findings in stable patients, as observation may be safer and avoids unnecessary complications. 3

Monitoring and Follow-Up

• Patients with chest tubes require close monitoring for signs of tension pneumothorax during evacuation, especially if under positive pressure ventilation. 1
• If symptoms of tension pneumothorax develop, first exclude kinking in the chest tube or connecting tube, then secure the connection to the drainage equipment. 1
• For delayed presentation of traumatic hemothorax (>24 hours post-injury) with respiratory compromise, chest tube insertion remains indicated even in the delayed setting. 2, 6