Practice management guidelines for management of hemothorax and occult pneumothorax.

STATEMENT OF THE PROBLEM Thoracic trauma is a notable cause of morbidity and mortality in American trauma centers, where 25% of traumatic deaths are related to injuries sustained within the thoracic cage.1 Chest injuries occur in 60% of polytrauma cases; therefore, a rough estimate of the occurrence of hemothorax related to trauma in the United States approaches 300,000 cases per year.2 The management of hemothorax and pneumothorax has been a complex problem since it was first described over 200 years ago. Although the majority of chest trauma can be managed nonoperatively, there are several questions surrounding the management of hemothorax and occult pneumothorax that are not as easily answered. The technologic advances have raised the question of what to do with incidentally found hemothorax and pneumothorax discovered during the trauma evaluation. Previously, we were limited by our ability to visualize quantities 500 mL of blood on chest radiograph. Now that smaller volumes of blood can be visualized via chest computed tomography (CT), the management of these findings presents interesting clinical questions. In addition to early identification of these processes, these patients often find themselves with late complications such as retained hemothorax and empyema. The approach to these complex problems continues to evolve. Finally, as minimally invasive surgery grows and finds new applications, there are reproducible benefits to the patients in pursuing these interventions as both a diagnostic and therapeutic interventions. Video-assisted thoracoscopic surgery (VATS) has a growing role in the management of trauma patients.