1) The document discusses whether all traumatic hemothoraces should undergo drainage or if some can be managed expectantly. 2) Recent studies have found that expectant management of hemothoraces may have benefits over drainage such as shorter hospital stays and fewer complications, but larger studies are still needed. 3) The T.H.R.E.A.T. trial aims to further study this question by randomly assigning traumatic hemothorax patients either to chest drainage or expectant management and comparing outcomes between the groups.

1. Hemothoraces: To Drain or not to drain ?
Chad G. Ball, MD, MSc, FRCSC, FACS
Hepatobiliary, Pancreas, Trauma and Acute Care Surgery
University of Calgary

2. HTX Precedent
Management of Hemothoraces
All hemothoraces, regardless of size, should be considered for
drainage (Level III).
J Trauma. 2011;70(2):510-518

3. ATLS
Management of Hemothoraces
All hemothoraces, regardless of size, should undergo drainage.

4. Alternative Rationale
• There is a precedent for expectant
management of significant
traumatic hemothoraces
J Coll Radiol Aust. 1964;8:48-54
SA Med Jrnl. 1965:548-53

7. More modern data…
• Hemothorax size threshold for pleural drainage?

8. Retained HTXs…
“…I need to know an answer to a different question…and that is,
of a given size hemothorax without intervention what is the
likelihood of that leading to… [complications]”
Dr. J. Wayne Meredith (Winston-Salem, NC)
J Trauma. 2011;72(1):11-24

9. Implications
• Pleural drainage is not a
benign procedure
• Potentially following an
ongoing trend of being less
invasive in trauma care
• Potential cost and resource
use implications could be
significant

10. Risks…

11. 22% rate of major complications

12. Questions
1. Should all traumatic hemothoraces be drained?
2. Are there predictors for hemothorax drainage?

15. Discussion
• Patients with small traumatic hemothoraces
were clearly being observed
– 808 patients (278 (34%) observed and 530 (66%)
had PD))
– Was not clear what the size threshold should be
– 300 cc threshold might be a basic minimum (?)

16. Conclusions…
• Expectant management of HTXs:
• Shorter length of stay
• Fewer empyemas
• Fewer tube thoracostomy related complications
• No difference in mortality
• If you begin to drain the chest, you must finish the job
Initial results deserve further study

17. T.H.R.E.A.T. Trial

19. Excluded if:
1. Penetrating thoracic injury
2. >24 hrs after admission
Participant data collection and analyses
Primary outcome
Subsequent thoracic interventions (i.e., additional chest tube insertion, image-guided drainage,
video-assisted thoracic surgery)
Secondary outcomes
Difference in empyema and ICU/hospital outcomes
Patients >17 years old without severe respiratory distress or hemodynamic instability who have a traumatic
Hemothorax detected on CT scan are ELIGIBLE
Randomize (one chest side only) with delayed consent
Online: http://www.opticc.com
Select Hemothorax RCT Tile at top of screen
Login: Calgary Password: Calgary
Chest drainage group
The size and type of catheter, placement
method, & timing of removal is at the
discretion of the attending clinician
Expectant management
No intra-pleural catheter
DOES YOUR PATIENT HAVE A TRAUMATIC MEDIUM/LARGE HEMOTHORAX?
T.H.R.E.A.T. - The Management of Traumatic Hemothoraces RCT

20. Thank-you!Thanou!
Thank-you!