Quote:
Originally Posted by RichL025
No offense, but he should have had a needle or chest tube RIGHT AT THIS POINT.
XRay should have been an afterthought to confirm your proper chest tube placement.
No, you DID have an hour. You had several hours. He has already demonstrated that his hemothorax is not that brisk (he accumulated those 850 ccs in his chest over the 4 hours he was sitting there), not in the seconds after you placed the tube) and you addressed his limmediate life-threatening injury already.
I would submit you have no options other than transferring the patient to a trauma center. An ED thoracotomy has a dismal save rate (to hospital discharge) in experienced hands.
Give him two large bore lines, get blood flowing, FFP and platelets as necessary, and get him to a trauma center stat.
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Good points. However, my assumptions upon entering the room were that he had been recently been evaluated by a competent senior attending physician who had worked him up and had been watching him for 4 hours. I wanted to know what caused his sudden change while prepping for what I felt certain to be a needle followed by a tube thoracostomy.
Secondly, if you read carefully, I said he passed 850 cc. The drainage stopped at around 1250. Also the CXR done 2 hours previous showed no signs of hemothorax. So as far as I knew, this was new fairly well oxygenated blood, and he was young and athletic so could compensate fairly well before a sudden crash. The time between 850 and 1250 cc was quite anxiety provoking as, at that point given the information I had, I was not in a position to assume that he did not have an active bleed as you suggest.
The point you bring up about survivability of ED thoracotomy is key. The question running through my head was, "what if this is an active bleed and this guy decompensates? Am I going to let him die right here in front of me without doing anything?" In the end you were right. The blood coming out of the tube did stop - albeit at 1250 cc. He remained stable, and was transferred to a Level 1 Trauma Center.
However, the answer to the questions running through my head at the time was, "With my lack of thoracic surgery training, I will not crack his chest." The reason I brought this up is that this is a frequent question we face in the ED and in residency training programs that attracts much debate.