Indications for operative intervention

A modest number of patients with chest trauma require early operative intervention. The most common indication for thoracotomy is significant blood loss into the chest cavity. Guidelines for operation are an initial loss of at least 1500 cm 3 of blood upon placement of the chest tube, or continued bleeding of 200 to 300 cm 3/h. However, patients with ongoing hemodynamic instability require operative intervention in order to obtain hemostasis even if these arbitrary threshold values are not exceeded. Thoracotomy is also indicated if a large hemothorax cannot be adequately evacuated from the chest by tube thoracostomy, although the timing of this procedure is controversial. Other indications for early thoracotomy or median sternotomy are injuries to the heart, aorta, or other great vessels, tracheal or major bronchial injuries, and esophageal injuries. Diaphragmatic injuries are usually approached through the abdomen because of the common association with other intra-abdominal injuries.

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