see also: [[Chest trauma radiology#haemothorax]], [[Thoracostomy|ICC]] See: [Dunn - pulmonary injuries](x-devonthink-item://68C7574E-C7F8-4D99-91C4-B6FE4965AF31) ## Indications for Thoracotomy - blood loss from ICC in stable patient - \>200 mL/hour for 3 hours - \> 1500 mL in total - blood loss from ICC in unstable patient - \>100mL/hour - \>1000mL in total ## Indications for ICC - Any haemothorax can be considered for drainage (EAST) with initial drainage attempt with tube thoracostomy - haemodynamically/physiologically abnormal haemothorax requires immediate finger thoracostomy followed by chest tube insertion (Western Trauma) - significant haemothorax >300mL - Small haemothorax <300mL can be considered for management with observation and repeat imaging ## How does an ICC improve treatment for haemothorax? - There is a common misconception that haemothorax may "tamponade" on its own without intervention. Given the low-pressure system of the chest, this is very unlikely to be true (and if intrathoracic pressures *were* high enough to achieve this, it would independently be an indication for chest tube). - retained haemothorax is an independent predictor for **emyema** development - drainage allows **lung re-expansion** and **improvement in respiratory function** - clots can act as **local anticoagulant** by releasing fibrinolysins → prolonged bleeding - retained haemothorax (>300mL) can cause **fibrothorax** in addition to empyema - massive haemothorax: - hypovolaemia → ↓ preload → ↓ cardiac output - collapsed lungs → hypoxia and alveolar hypoventilation, V/Q mismatch, anatomic shunting - hydrostatic pressure of haemothorax compresses vena cava and pulm parenchyma → further pre-load impairment and ↑ pulmonary vascular resistance