Abstract
Introduction: Trauma guidelines state that a thoracotomy should be performed if tube thoracostomy output reaches 1500mL promptly or 200mL every hour for 2-4 hours. However adhering to this rule religiously will lead to poor outcomes in some patient groups, particularly in those with blunt injuries. These patients likely have bleeding perpetuated by an acquired traumatic coagulopathy, which is not surgically amendable. This is a case report describing a patient who sustained blunt injuries who although had 1500mL of initial blood loss after tube thoracostomy insertion, by adhering to the principles of damage control resuscitation, his chest bleeding stopped and a thoracotomy was avoided.
Case report: A 68 year old male fell from a ladder and sustained catastrophic head and chest injuries. He had a history of cardiac disease and was taking clopidogrel. A chest drain was placed and 1500mLs was promptly evacuated. Although this level of bleeding would usually necessitate a thoracotomy, there was concern that this bleeding was actually due to a profound coagulopathic state. His initial measures of coagulation function on ROTEM confirmed this coagulopathy and he was aggressively treated blood products and tranexamic acid with damage control principles. Once his coagulation function had returned, his chest bleeding ceased. Unfortunately the patient was unable to recover from his head injuries and died in hospital on day 10 post-injury.
Conclusion: The idea that a trauma thoracotomy should be performed if thoracic bleeding reaches pre-defined thresholds is too simplistic and does not take into account the complex physiology that occurs in those with significant injury. Without care, a trauma thoracotomy in the wrong patient will add to the patient’s injury burden, worsening their outcome. The primary focus needs to be on appropriate resuscitation including the assessment of coagulation function before a surgical intervention is considered.

Key words: thoracotomy, damage control resuscitation, coagulopathy, ROTEM