A portable chest x-ray performed at Patient Arrival Time (PAT) +

A portable chest x-ray performed at Patient Arrival Time (PAT) + 10 min revealed a right hemothorax. A right thoracostomy tube was placed, which returned 800 mL of blood. By this time the patient had responded to resuscitation of 2 L of Lactated Ringers (PAT + 20 min). The patient did not at this time meet criteria for an emergent thoracotomy (< 1500 mL thoracostomy output and hemodynamic stability), therefore planning the workup 3-deazaneplanocin A molecular weight for potential surgical sources of bleeding incorporated 3 areas of concern: 1) intra-thoracic injury resulting from

the lower right thoraco-abdominal wound, 2) intra-abdominal injury from the lower right thoraco-abdominal wound that was decompressing BIBW2992 datasheet through a diaphragm injury into the right thoracic cavity and 3) injury to the proximal great vessels from the Zone I neck wound decompressing into the right

thoracic cavity. We believed that distinguishing between these three possibilities was important in so far that the optimal surgical approach to each area was different: 1) posterior thoracotomy for thoracic injury, 2) laparotomy for abdominal and 3) median sternotomy/clavicular extension for proximal great vessel exposure. A focused abdominal sonogram for trauma (FAST) done at PAT + 20 min was negative. Given the range of possible injuries and the patient’s current stability, a Computer Tomography Angiogram (CTA) of the neck and chest and a CT scan of the abdomen were performed at PAT + 40 min. Although no contrast extravasation suggestive of active bleeding was appreciated on CT, a residual clot occupying the > 50% of the right chest was appreciated (see Figure 1). There was no evidence of intra-abdominal injury on the CT scan of the abdomen. A second thoracostomy tube Thymidine kinase was placed and approximately 2.2 L of blood were evacuated with suction. Given that this output now met criteria for surgical exploration, the PLX4032 order decision was made to take the patient to the operating room for an exploratory thoracotomy (PAT + 60 min). Resuscitation up to this point consisted

of 4 L of crystalloid and 6 units of PRBCs. Figure 1 CTA of chest revealing large residual clot in the right hemi-thorax. This study was performed in an attempt to localize the bleeding source in our patient. The study was negative in terms of identifying an anatomic source of bleeding (most relevant with respect to examination of the great vessels in the thoracic outlet, albeit falsely negative). However, this study served as a proxy for the post-thoracostomy chest x-ray and identified the insufficient drainage of the right chest with the thorocostomy tube in place. As a bleeding source had not yet been identified, all three potential areas of injury remained viable concerns. Given this uncertainty, the decision was made to utilize the surgical approach that would provide the greatest flexibility for our set of potentialities.

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