A 32-year-old man sustains blunt chest trauma in a fall from height. A right-sided chest drain is inserted for haemothorax and drains 1300 mL of blood immediately. Over the next 3 hours the drain continues to output 250 mL per hour and he remains tachycardic despite transfusion. The most appropriate next step is:

• A Urgent thoracotomy ✓
• B Insertion of a second intercostal drain
• C Continue observation with hourly drainage measurement
• D CT thorax with contrast

Explanation

C massive haemothorax is defined by ATLS criteria as an initial drainage exceeding 1500 mL, or ongoing loss above 200 mL per hour for 2 to 4 hours, and it mandates operative exploration because it indicates active arterial bleeding, usually from an intercostal or internal mammary vessel. This patient meets both thresholds. C second drain or observation would delay control of haemorrhage, and CT has no role in an exsanguinating patient.

Reference: Sabiston Textbook of Surgery, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.