WBR289

Author	[[PageAuthor::Gonzalo A. Romero, M.D. [1]]]
Exam Type	USMLE Step 2 CK
Main Category	Surgery
Sub Category	Respiratory
Prompt	A 34-year-old male gets into a street fight. He is stabbed in the right chest. He develops shortness of breath and is brought to the ER. His vitals upon admission were T 37C, BP= 110/70mmH, 85 bpm, 18 respirations/min. His chest has an 1 cm entrance wound on the right mid-axillary line at the 9th rib level. His lungs have no breath sounds at the right base and distant apical breath sounds. There is dullness to percussion over the right base. The rest of the physical exam is unremarkable. The CXR reveals a hemothorax. A chest tube is placed at the right pleural base recovering 260mL of blood per hour during the first four hours and starts deteriorating. What is the most appropriate next step in management?
Answer A	Chest tube replacement
Answer A Explanation	Incorrect.
Answer B	Thoracotomy
Answer B Explanation	Correct. The patient has drained through the chest tube more than 250 mL/hr for 4 hours, therefore a thoracotomy or thoracoscopy is necessary to ligate the vessel.
Answer C	Left chest tube insertion
Answer C Explanation	Incorrect. Bilateral chest tube placement is indicated in the case of a flail chest.
Answer D	CT scan with contrast
Answer D Explanation	Incorrect. The patient is hemodynamically stable therefore he cannot be placed into a CT scanner.
Answer E	Positive pressure ventilation
Answer E Explanation	Incorrect. This could be the next step in management if the patient starts desaturating.
Right Answer	B
Explanation	[[Explanation::This patient is presenting with a hemothorax which is draining 260mL/hr for the first four hours, a total of 1040mL during the first 4 hours. The criteria for thoracotomy is when the chest tube placed drains the following: More than 250 mL/hr for 4 hours= 1 Liter in 4 hours More than 2.5 Liters in 24 hours 1.25 Liters at chest tube insertion This criteria is a sign that the bleeding comes from a high pressure, or systemic circulation or a major hemothorax, therefore exploration through thoracotomy or thoracoscopy, and vessel ligation is necessary to stop the bleeding. The most likely source of bleeding is an intercostal artery. Educational Objective: A thoracotomy or thoracoscopy is indicated when there is more than 1 Liter of blood coming out of a chest tube in a 4 hour period. References: Master the Boards for Step 2CK, surgery chapter See also: Thoracotomy and Hemothorax Educational Objective: References: ]]
Approved	No
Keyword	Thoracotomy, chest tube, hemothorax
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