01Approach to the Critical Patient/attcp67

Immediate priorities

›Life threats

›Hemorrhagic shock

›Massive hemothorax

›Ongoing intrathoracic bleeding

›Ventilatory failure

›Lung collapse

›Associated pneumothorax

›Obstructive physiology

›Tension hemothorax

›Mediastinal shift

›Concurrent injuries

›Penetrating chest trauma

›Blunt thoracic trauma

›Major vascular injury

›Airway and breathing

›High-flow oxygen

›Target SpO2 94-98%

›Lower target 88-92% if chronic hypercapnia risk

›Ventilation support

›Assisted ventilation for fatigue

›Early intubation if refractory hypoxemia

›Immediate decompression triggers

›Severe respiratory distress with unilateral absent breath sounds

›Hypotension with suspected tension physiology

›Circulation and hemorrhage control

›IV access and monitoring

›Two large-bore IVs

02History/hx60

Core features

›Presenting syndrome

›Pleuritic chest pain

›Side localization

›Sudden onset after trauma

›Dyspnea

›Progressive over minutes to hours

›Exertional limitation

›Hemodynamic symptoms

›Lightheadedness

›Syncope

›Cough

›Hemoptysis

›Sputum changes

›Time course

›Onset timing

›Immediate post-injury

›Delayed presentation

›Progression

›Worsening dyspnea

›Increasing chest pain

›Mechanism and context

›Trauma mechanism

›Blunt

›MVC

›Fall

›Crush injury

›Penetrating

03Physical Exam/exam43

Key findings

›Respiratory assessment

›Work of breathing

›Accessory muscle use

›Inability to speak full sentences

›Auscultation

›Decreased breath sounds on affected side

›Reduced air entry at bases

›Percussion

›Dullness over affected hemithorax

›Hyperresonance suggesting concurrent pneumothorax

›Chest wall

›Tenderness

›Crepitus

›Flail segment

›Hemodynamics

›Shock features

›Tachycardia

›Hypotension

›Cool extremities

›Neck veins

›Flat neck veins with hypovolemia

›Distended neck veins with tension physiology

›Skin and trauma survey

›Penetrating wounds

›Location mapping

›Entrance and exit wounds

›Ecchymosis patterns

04Differential Diagnosis/ddx46

Life-threatening causes of dyspnea and shock

›Traumatic thoracic bleeding

›Hemothorax (J94.2)

›Traumatic hemothorax (S27.1XX)

›Massive hemothorax

›Great vessel injury

›Thoracic aortic injury

›Subclavian vessel injury

›Cardiac injury

›Pericardial tamponade

›Myocardial contusion

›Pleural space disorders

›Tension pneumothorax

›Hyperresonance

›Tracheal deviation

›Large pneumothorax

›Pleuritic pain

›Hypoxemia

›Pulmonary parenchymal disorders

›Pulmonary contusion

›Hypoxemia out of proportion to exam

›Imaging infiltrates

›Aspiration

›Vomiting

›Altered mental status

›Thromboembolic disease

›Pulmonary embolism (I26.99)

›Risk factors without trauma explanation

05Laboratory Tests/lt37

Initial labs

›Bleeding and perfusion assessment

›Complete blood count

›Hemoglobin baseline for trend

›Platelets for bleeding risk

›Coagulation profile

›INR

›aPTT

›Fibrinogen

›Low fibrinogen suggesting consumptive bleeding

›Replacement trigger per massive transfusion protocol

›Type and screen

›Crossmatch for anticipated transfusion

›Massive transfusion activation coordination

›Metabolic and end-organ markers

›Venous or arterial blood gas

›Lactate for shock severity

›pH for perfusion adequacy

›PaO2 in mmHg if arterial sample

›Basic metabolic panel

›Potassium for transfusion planning

›Creatinine for contrast planning

›Calcium

›Ionized calcium for citrate toxicity

›Replacement threshold per protocol

Targeted tests

›Medication and toxin context

›Anti-factor Xa level

06Diagnostic Tests/dt54

Scoring Systems

›Hemorrhage and transfusion prediction

›ABC score for massive transfusion

›Penetrating mechanism

›Positive FAST or eFAST

›SBP 90 mmHg or less

›Heart rate 120 beats/min or more

›Shock index

›Heart rate divided by SBP

›Values above 0.9 suggesting increased risk of significant hemorrhage

›TASH score

›Hemoglobin

›Base excess

›SBP

›Heart rate

›FAST result

›Long bone or pelvic fracture indicators

MRI

›Limited role

›Non-acute evaluation

›Chronic organizing hemothorax characterization

›Pleural mass differentiation if stable and unclear etiology

›Constraints

›Not for unstable trauma patients

›Time and monitoring limitations

CT

›CT chest with IV contrast

›Indications

07Disposition/dispo40

Level of care

›Admission criteria

›Any traumatic hemothorax needing tube thoracostomy

›Continuous monitoring requirement

›Serial drainage assessment

›Ongoing oxygen requirement

›Persistent hypoxemia

›Need for noninvasive ventilation

›Significant associated injuries

›Multiple rib fractures

›Pulmonary contusion

›ICU criteria

›Hemodynamic instability

›Vasopressor requirement

›Ongoing transfusion requirement

›Massive hemothorax indicators

›Large initial chest tube output

›Continued high output

›Ventilatory support

›Intubated patient

›High-flow oxygen requirement

›Operative or procedural pathway

›Immediate OR

›Massive hemothorax criteria met

›Persistent shock with ongoing intrathoracic bleeding

›Early VATS consideration

›Retained hemothorax on imaging

›Persistent fever or leukocytosis with pleural collection

08Treatment/t103

Pleural drainage

›Tube thoracostomy strategy

›Indications

›Moderate to large traumatic hemothorax

›Symptomatic small hemothorax

›Hemopneumothorax

›Tube selection

›Large-bore tube

›Typical adult size 28-36 Fr

›Larger size for viscous clot burden

›Pigtail catheter

›Consider in select stable patients with small hemothorax

›Close monitoring for failure and retained clot

›System setup

›Water seal system

›Initial suction if large collection or persistent air leak

›Transition criteria to water seal after lung re-expansion

›Output tracking

›Initial output measurement

›Quantified volume documentation

›Immediate escalation threshold 1500 mL

›Ongoing output trend

›Hourly measurement initially

›Escalation threshold 200 mL/hour for 2-4 hours

›Evidence framing

›Tube thoracostomy for traumatic hemothorax as standard of care (Class I, expert consensus)

›Massive hemothorax thoracotomy criteria as standard trauma consensus (Class I, expert consensus)

Resuscitation and hemorrhage control

›Blood product resuscitation

›Massive transfusion protocol

›Early activation in suspected major bleeding

›Balanced component therapy per institutional protocol

›Calcium replacement

›Calcium chloride IV

›1 g IV

›Repeat dosing guided by ionized calcium

›Calcium gluconate IV

›3 g IV

›Alternative if peripheral access only

›Temperature management

›Active warming to prevent coagulopathy

›Warmed fluids and blood products

›Antifibrinolytic therapy

›Tranexamic acid

›If within 3 hours of major trauma and suspected significant bleeding

›Initiate 1 g IV over 10 minutes

›Follow with 1 g IV over 8 hours

›Avoid initiation beyond 3 hours after injury due to harm signal in trauma literature

Analgesia and supportive care

›Analgesia plan

›Opioid options

›Fentanyl IV

›25-50 micrograms IV

›Repeat every 5-10 minutes to effect

›Monitor for respiratory depression

›Hydromorphone IV

›0.2-0.5 mg IV

›Repeat every 10-15 minutes to effect

›Longer duration caution in older adults

›Non-opioid adjuncts

›Acetaminophen PO or IV

›1000 mg

›Maximum 4000 mg per 24 hours

›Lower maximum in liver disease

›NSAID use

›Avoid if active bleeding concern

›Consider if bleeding controlled and renal function adequate

›Gastroprotection if high risk

›Regional analgesia

›Serratus anterior plane block

›Consider with multiple rib fractures

›Improved ventilation via pain control

›Coordinate with anesthesia or trained provider

Anticoagulant and antiplatelet reversal

›Reversal framework for life-threatening bleeding

›Vitamin K antagonist

›PCC dosing per INR and weight

›Institutional protocol dosing

›Concurrent vitamin K 10 mg IV

›Repeat INR monitoring

›Direct thrombin inhibitor

›Idarucizumab for dabigatran

›5 g IV total

›Two 2.5 g doses

›Rebound anticoagulation monitoring

›Factor Xa inhibitor

›PCC consideration when life-threatening bleeding

›Institutional protocol dosing

›Anti-factor Xa guided decisions if available

›Thrombosis risk discussion

Definitive hemorrhage control

›Operative management triggers

›Thoracotomy indications

›Initial chest tube output >1500 mL

›Suggests major vascular injury

›Immediate surgical control need

›Ongoing output >200 mL/hour for 2-4 hours

›Persistent bleeding despite drainage

›Operative exploration need

›Retained hemothorax management

›Early VATS

›Persistent pleural collection after tube

›Infection risk reduction

›Improved lung re-expansion

›Intrapleural fibrinolytics

›Consider in select non-operative candidates

›Higher bleeding risk consideration in trauma

›Specialist-guided decision

09Special Populations/sp49

Pregnancy

›Maternal and fetal considerations

›Physiologic changes

›Lower baseline PaCO2

›Reduced functional residual capacity

›Imaging principles

›eFAST and CXR prioritized

›CT with shielding when benefits outweigh risks

›Resuscitation priorities

›Maternal stabilization first

›Left uterine displacement in late pregnancy

›Medication considerations

›Avoid NSAIDs in later pregnancy

›Opioid use with monitoring

›Obstetric consultation triggers

›Viable gestation with significant trauma

›Fetal monitoring needs

›Rh immunoglobulin considerations if indicated

Geriatric

›Higher risk profile

›Anticoagulant prevalence

›Lower threshold for reversal pathway consideration

›Lower tolerance for blood loss

›Pulmonary reserve limitations

›Earlier oxygen and ventilatory support

›Lower threshold for ICU admission

›Analgesia sensitivity

›Lower initial opioid dosing

10Background/b41

Epidemiology

›Burden and patterns

›Trauma association

›Common with rib fractures and pulmonary contusion

›More frequent in penetrating chest trauma

›Clinical spectrum

›Small occult hemothorax

›Massive hemothorax with shock

›Complication rates

›Retained hemothorax risk after inadequate drainage

›Empyema risk with retained blood

Pathophysiology

›Mechanism

›Pleural space blood accumulation

›Lung compression and atelectasis

›Ventilation-perfusion mismatch

›Bleeding sources

›Intercostal arteries and veins

›Internal mammary vessels

›Pulmonary parenchymal laceration

›Great vessel injury

›Hemodynamic impact

›Reduced venous return with large volume

›Hypovolemic shock from blood loss

›Retained clot evolution

›Fibrin organization

›Pleural peel and trapped lung

11Patient Discharge Instructions/pdi24

copy discharge instructions

›Discharge instructions

›Diagnosis

›Hemothorax

›Chest trauma with pleural blood

›Activity

›Avoid heavy lifting and contact sports until cleared

›Deep breathing and gentle coughing exercises

›Pain control

›Acetaminophen as directed

›Avoid NSAIDs unless specifically advised

›Follow-up

›Follow-up appointment within 24-72 hours if discharged with small hemothorax

›Repeat chest radiograph per plan

›Return to ED immediately for

›Worsening shortness of breath

›New chest tightness or severe chest pain

›Fainting or near-fainting

›Rapidly worsening weakness

›Fever or shaking chills

›Coughing up blood

›Chest tube specific

›Increasing drainage volume or new bright red blood

›New air leak sound from device

›Tube dislodgement or dressing saturation

12References/r16

Guidelines and evidence sources

›Trauma and pleural blood references

›ATLS trauma management framework for thoracic trauma

›Tube thoracostomy indications for traumatic hemothorax

›Massive hemothorax operative escalation thresholds

›EAST practice management guidelines on hemothorax and occult pneumothorax

›Drainage strategies and retained hemothorax management

›Early VATS considerations

›British Thoracic Society pleural disease guidance

›Pleural space management principles

›Complication prevention concepts

›Trauma massive transfusion literature

›Balanced component therapy strategies

›Tranexamic acid early trauma use evidence base

›eFAST and thoracic ultrasound literature

›Pleural fluid detection performance characteristics

›Integration into trauma primary survey

Evidence & Review

Evidence & Review