Stable Penetrating Chest Trauma

Annotation for Point E

Traditionally, when hemothorax is suspected or diagnosed, large-bore chest tubes (36-40 Fr) have been advocated. These tubes may actually be too big for smaller patients and are associated with increased pain. Smaller-bore (28-32 Fr) chest tubes or a range of pleural catheters (11-16 Fr)may be as effective in stable patients with less pain associated with placement.^14,38,39 Whatever the size of the initial drainage tube, residual hemothorax is a significant risk factor for the development of empyema. The primary risk factor for empyema is the need for a chest tube. Thus, this does not apply to the residual small untapped or drained hemothorax.⁴⁰ Patients with a hemothorax still apparent after tube drainage in the trauma bay on plain CXR or large collections noted on chest computed tomography (CT) have up to a 25% incidence of empyema, particularly with a residual hemothorax of greater than 300 cc.^35,41 CT scan is much more accurate in predicting the volume of retained hemothorax than plain CXR. Early washout and evacuation within 72 hours is optimal. Techniques can include pleuroscopy, video thoracoscopy (VATS), or thoracotomy. VATS has been favored over placing more chest tubes, the former being associated with quicker resolution and with fewer complications.³⁵ Instillation of thrombolytic agents has been described and is associated with a delay in resolution, increased cost, and possibly increased complications in the trauma setting.⁴²  The majority of organisms associated with posttraumatic empyema are gram positive, but it is not clear whether ‘‘prophylactic’’ antibiotics independently reduce the risk.^16,43 Nevertheless, most centers administer at least one dose of antibiotics that covers gram-positive organisms as soon as practical.