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Chest Tube Management Protocol for Traumatic Chest Wall Injury

Definition

Structured management pathway for patients with pneumothorax (PTX), hemopneumothorax (HPTX), or hemothorax (HTX) following traumatic chest wall injury. The goal is to ensure safe, timely chest tube management and minimize retained hemothorax, empyema, or prolonged tube duration.

Principles

  • All traumatic chest injuries with PTX, HPTX, or HTX require prompt chest tube placement and post-placement imaging confirmation.
  • All chest tubes should be placed on –20 mmHg suction initially.
  • Early imaging at 24 hours post-placement guides ongoing management.
  • Decision-making depends on air leak status, drainage volume, and radiographic findings.

Stepwise Evaluation

1. Initial Management

  1. Chest Tube Placement
  2. Indications: PTX, HPTX, HTX following trauma.
  3. Apply –20 mmHg suction to all chest tubes.
  4. Obtain imaging (CXR) to confirm proper placement and lung re-expansion.

2. 24-Hour Chest X-Ray Evaluation

A. PTX or HPTX

  • Findings: Resolved PTX, no new or worsening subcutaneous emphysema (subQE)
  • Pleurovac: No air leak, <300 mL effluent in the last 24 hours
  • Patient: Not intubated on high ventilatory settings
  • Action: Transition to water seal (WS)

B. Persistent Opacities or Pleural Effusion

  • Findings: Persistent pleural effusion or opacity on 24h CXR
  • Action: Order CT chest for retained hemothorax (RH) evaluation

C. Hemothorax (HTX)

  • Findings: No persistent pleural effusion or opacity, <300 mL effluent in 24 hours
  • Action: Remove chest tube
  • Follow-up: Obtain CXR 4 hours post removal

3. Water Seal Phase

  • 4-Hour CXR after WS
  • No new or stable PTX
  • No air leak
  • <300 mL effluent in last 24 hours
  • No worsening subQE
  • Not on high ventilator settings
  • Action: Remove chest tube and obtain 4-hour post-pull CXR

4. CT Chest Findings (Retained Hemothorax)

  • If RH volume <300 mL: Continue conservative management, observe.
  • If RH volume >300 mL:
  • Assess surgical candidacy:
    • Not a surgical candidate: Begin intrapleural fibrinolytic therapy (IPFT)
    • Alteplase 10 mg + Dornase alfa 5 mg daily × 3 days
    • Repeat CT chest after 3 days
    • Surgical candidate: Proceed to VATS or thoracotomy for evacuation

Management Summary (Text-Based Algorithm)

  1. Chest tube placement → suction → confirm on CXR
  2. At 24h:
  3. If resolved PTX/HPTX → water seal
  4. If persistent opacities/effusion → CT chest
  5. If resolved HTX and <300 mL drainage → remove chest tube
  6. After water seal (4h):
  7. If no PTX/air leak → remove chest tube
  8. If CT shows RH >300 mL:
  9. Poor candidate: IPFT
  10. Good candidate: VATS/thoracotomy

Trauma and Acute Care Surgery (ACS) Policy on Chest Tube Placement

  • The decision and placement of chest tubes in trauma patients are determined by the Trauma Chief or Trauma Resident.
  • If a patient is evaluated by the Emergency Department (ED) for non-trauma-related effusion (e.g., malignant or parapneumonic effusion), the ED will consult ACS for assistance with chest tube management.
  • ACS will supervise the procedure, but the ED resident performs the chest tube insertion under ACS supervision.
  • All chest tube placements require post-procedural imaging and documentation of supervision in the medical record.

Red Flags / Urgent Triggers

  • Worsening PTX or new air leak
  • Drainage >300 mL/24h
  • Increasing subcutaneous emphysema
  • Persistent or enlarging pleural opacities on CXR or CT
  • Clinical instability or respiratory compromise

References

  • Washington University Department of Surgery, 2024. The Washington Manual of Surgery, 9th Edition.
  • Cameron JL, Cameron AM. Current Surgical Therapy, 14th Edition, Elsevier, 2023.
  • de Virgilio C, Grigorian A. Surgery: A Case-Based Clinical Review, 2nd Edition, Springer, 2020.
  • EAST Practice Management Guidelines Committee, 2018. Management of Retained Hemothorax After Trauma.
  • *Institutional Trauma and ACS Policies, 2025.