1. Retained Hemothorax & Empyema
Hassan Bukhari
Trauma Fellow
10/12/10

2. Objectives By the end of this discussion, you will be familiar with
Incidence and risk factor
Diagnostic tools
Treatment options
Medical
Surgical
Timing of intervention

3. Content Retained Hemothorax Incidence, risk factors & complication
Prevention
Treatment options
Chest tube vs Medical vs Surgical
Empyema
Incidence & risk factors
Diagnosis & stages
PCD vs VAT vs Thoracotomy
Techniques, timing, outcome

4. Retained Hemothorax Chest tube fails to drain hemothorax in 5%
It can progress into
Empyema (<10%)
Fibrothorax (3 months)
Risk factor for complications
Prolonged ventilation
Pneumonia
Violation of the pleura
Chest tube
Foreign body (missile)

5. Diagnosis

6. Prevention Early drainage Do we have to drain all hemothoraces?
Chest tube
Sterile technique
Prophylactic antibiotics

7. Chest tube Mainstay of treatment
Only needed treatment in >90% of thoracic trauma
Success rate can be improved by suction and irrigation (anecdotal)
Timing
Within 7 days from injury
If did not drain it appropriately
2nd chest tube
Within 1-2 days

8. If the 2nd chest tube failed
Intrapleural thrombolytics
VATS
Thoracotomy with decortication

9. Empyema Hippocrates 1st to describe empyema
“In pleuritic afflictions when the disease is not purged off in 14 days, it usually results in an empyema.”

10. Empyema Surgical management
“prepare a warm bath, set him on a stool, which is not wobbly … listen to see on which side a noise is heard; and right at this place, preferably on the left, make an incision, then it produces death more rarely.”

11. Empyema
Pus in the pleural cavity: Exudate effusion (PL/SL >0.6), pH <7.2
Culture is negative in 1/3 of the patients
Incidence is increasing (5%)
Risk factors
Ventilated patient, Pneumonia
Poor pain control, Chest tube
Extrathoracic infection
Diagnosis
Clinical + CXR + US +/-CT

12. Rim enhancement on CT

13. Stages Stage I (acute, serous) Stage II + III Subacute  chronic
Within the 1st week
Thin exudate
Chest tube is the treatment of choice
Stage II + III
Subacute  chronic
Thick exudate with debris

14. Stages

15. Treatment Good evidence is lacking Posttraumatic vs nontraumatic
More likely to fail chest tube drainage and more likely to require surgical intervention

16. Main goals of treatment
Antibiotics coverage
Complete drainage of empyema
Debridement + decortication
Full re-expansion of the lung
Assess underlying lung
Management of residual space

17. Treatment

18. Treatment Diamond

19. Medical therapy Thrombolytic therapy
Not superior to chest tube* (MIST)
Better success with C. tube
Inferior to surgical therapy
High failure rate, increase length of stay, higher cost
Reserved for
High operative risk patient
Early post operative intervention
Clot is soft and easier to be lysed
Maskell NA, et al. U. K. Controlled trial of intrapleural
streptokinase for pleural infection. N Engl J Med 2005; 352:865–874.

20. Treatment based on the stage

21. VAT VATS vs Thoracotomy
Better success rate when done during early stages (<4 wks)
Conversion rate 8%
Techniques
Evacuation of the pus
Pealing off the visceral pleura (decortication)
Elimination of the cavity (lung expansion)

22. Patient placement + ports

23. Ports placement

24. Port placement

25. VAT

26. Thoracotomy Method of choice
>80% of posttraumatic empyema will need open drainage
You have to wait for several week for plane to mature
Types
Mini muscle-sparing (axillary) thoracotomy vs.Full thoracotomy (FT)
Open window (OWT) thoracostomy

27. Thoracotomy incision
8th rib resection, between MA and PA lines

28. Rib resection

29. Decortication

30. VAT vs. Mini T vs. Full T
* Rev Bras Cir Cardiovasc vol.18 no.4 São José do Rio Preto Nov./Dec. 2003

31. Open window thoracostomy
Mastery of Cardiothoracic Surgery 2nd Edition (2007)

32. Outcome Mortality per procedure Chest tube alone 24%
Thoracotomy and decortication up to 6.6%
VATS 4.5%

33. What did we cover? You should be familiar with
Incidence and risk factor
Diagnostic tools
Treatment options
Medical
Surgical
Timing of intervention

34. References
Asensio J, Trunkey D. Current Therapy of Trauma and Surgical Critical Care.
Maskell NA, Davies CWH, Nunn AJ, et al. U. K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005; 352:865–874.
Lee S, et al. Thoracic empyema: current opinions in medical and surgical management. Current Opinion in Pulmonary Medicine 2010,16:194–200
Sabiston D, Spencer F. Surgery of the Chest. 6th edition (1995)