A 28-year-old man sustains blunt chest trauma. CXR shows a large left haemothorax. A chest drain is inserted and drains 1,600 mL of blood immediately, with ongoing haemorrhage of 300 mL/h. He is haemodynamically unstable despite resuscitation. According to ATLS guidelines, what is the MOST appropriate next step?

• A Insert a second chest drain on the same side
• B CT chest with contrast to identify the bleeding vessel
• C Autotransfusion of the drained haemothorax only
• D Emergency thoracotomy (or VATS) for surgical haemostasis ✓

Explanation

The indications for surgical intervention (emergency thoracotomy or VATS) for haemothorax include: immediate drainage >1,500 mL (massive haemothorax on tube thoracostomy), OR ongoing haemorrhage >200 mL/h for 2–4 hours, OR haemodynamic instability despite resuscitation. This patient meets all three criteria. CT angiography is contraindicated in the haemodynamically unstable patient requiring immediate operative control. A second drain would not address the underlying haemorrhage. Autotransfusion of shed blood is an adjunct but does not treat the source.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.