Traumatic hemothorax: Is decortication necessary?

Abstract

Recent recommended management of traumatic hemothorax has included early thoracotomy to evacuate clotted blood (“decortication”) and thereby to prevent early and late pleural sequelae. This report reviews the management and results in 452 patients with hemothorax caused by penetrating (338 cases) or blunt trauma (114 cases). The patients were placed into two groups: Group I consisted of 408 patients who had pleural drainage as the only operative treatment for hemothorax. Group II comprised 44 patients who also had thoracotomy. The primary indications for thoracotomy were massive or persistent pleural blood drainage, cardiac tamponade, vascular injury, pleural contamination, débridement of devitalized tissue, sucking chest wounds, and major bronchial air leak. Thoracotomy was not done just because there was chest roentgenographic evidence of residual hemothorax. Group I patients were divided into subgroups A or B determined by whether or not a chest roentgenogram taken after insertion of the tube showed adequate removal of pleural blood. Two hundred ninety patients were classified as Group IA with no residual hemothorax, and 118 patients were Group IB with residual hemothorax after chest tube drainage. In long-term follow-up, abnormal chest x-ray findings were observed in all groups but were frequent in the more severely injured patients of Group IB and Group II. Empyema occurred with equal frequency whether or not there was hemothorax. Development of empyema was related to shock on admission, pleural contamination, pneumonia, and prolonged duration of catheter drainage. We concluded that prompt adequate chest tube drainage is usually sufficient treatment for traumatic hemothorax. Residual hemothorax can be managed expectantly and need not be managed by early decortication.