Chest gunshot wound: drain, output and urgent thoracotomy

The following scene is fictional and was written for teaching. A 22-year-old man arrives at the emergency department with a gunshot wound to the right hemithorax at the midaxillary line, with no exit wound. He is anxious, with a respiratory rate of 30 breaths per minute, a blood pressure of 96 over 60 mmHg and a saturation of 89 in 100. Breath sounds are absent on the right. Bedside ultrasound shows fluid in the right hemithorax and a pericardial sac without effusion. A chest drain is placed and, within a few minutes, the bottle receives a lot of blood. The team looks at the volume and at the clock: how much blood is too much, and how long should they wait?

This text summarizes the approach to a gunshot wound to the chest: the initial assessment, the role of ultrasound, chest drainage, the output criteria that indicate thoracotomy, penetrating cardiac injury and resuscitative thoracotomy. The content is educational, aimed at students and health professionals, and does not replace local protocols or the assessment of the surgical team.

Key points

• Most penetrating chest wounds are treated with chest drainage, but some require immediate surgery.
• Initial drain output above 1,500 mL or continuous output above 200 mL per hour for 2 to 4 hours are classic criteria for thoracotomy.
• Bedside ultrasound quickly detects pneumothorax, hemothorax and pericardial effusion.
• Cardiac tamponade can occur with little blood, because the normal pericardium holds little acute volume.
• Thoracotomy in the emergency room has better results in penetrating trauma, especially cardiac trauma, in patients with signs of life on arrival.
• A short prehospital time is associated with greater survival in hypotensive patients.

What is at stake in the chest

The chest contains the lungs, heart, great vessels, trachea, bronchi and esophagus, and the diaphragm separates it from the abdomen in a mobile way. A projectile that enters the chest can injure any of these structures and, depending on the phase of breathing, cross the diaphragm and reach the liver, spleen or stomach. Therefore, wounds below the nipple in front or below the tip of the scapula behind should raise suspicion of associated abdominal injury.

The review on the airway in penetrating chest trauma by Cakmak and colleagues lists associated injuries described in a series: hemopneumothorax in 32 in 100, great vessel injury and abdominal injury in 18 in 100 each, esophagus in 11 in 100, left recurrent laryngeal nerve in 8, spine in 7 and heart in 5 in 100 (Cakmak and colleagues, 2022). The list shows that the chest is rarely hit alone.

Time also counts. In a study of 908 patients with penetrating chest trauma treated at an urban center, 79 in 100 survived. An injury severity score of 16 or more and hypotension on arrival predicted mortality, and, among hypotensive patients, longer transport times were associated with higher mortality (Swaroop and colleagues, 2013). The authors concluded that shorter prehospital times are associated with greater survival.

The initial assessment

The trauma care sequence organizes the assessment. In the airway and breathing, the goal is to quickly recognize the injuries that kill within minutes: tension pneumothorax, open pneumothorax, massive hemothorax and cardiac tamponade. In circulation, hypotension in a chest wound should be treated as hemorrhage or tamponade until proven otherwise.

The findings that deserve immediate attention are:

• Respiratory distress, tachypnea and falling saturation.
• Absent or decreased breath sounds on one side.
• Tracheal deviation and jugular distension, which suggest tension pneumothorax.
• Sucking wound, with air moving in and out through the hole.
• Hypotension with jugular distension and muffled heart sounds, which suggest tamponade.
• Hypotension with collapsed jugular veins, which suggests hemorrhage.
• Extensive subcutaneous emphysema, which may indicate airway injury.

Counting the holes and locating the projectiles helps estimate the track. A track that crosses the mediastinum, from one side of the chest to the other, greatly increases the chance of injury to the heart, great vessels, trachea or esophagus. The text on diagnostic pause discusses why it is worth stopping and reviewing the track before concluding that the injury is only pulmonary.

Bedside ultrasonography

Ultrasonography in the emergency room changed the initial assessment of chest trauma. The extended focused assessment, known by the English acronym eFAST, examines the pericardium, the abdomen and both hemithoraces in a few minutes. A review of penetrating cardiac trauma notes that the classic signs of tamponade, such as Beck's triad, electrical alternans and pulsus paradoxus, have been superseded as diagnostic tools by the detection of pericardial fluid on ultrasonography (Lee et al., 2023).

In an Iranian study of 64 patients with penetrating chest trauma, initial ultrasonography had sensitivity and specificity of 100 in 100 for pneumothorax and hemothorax when compared with radiography and follow-up (Heydari et al., 2014). The number of events was small and the confidence intervals were wide, but the authors concluded that ultrasonography has acceptable accuracy in the initial assessment of these patients.

Ultrasonography also has limits. Small hemothorax, extensive subcutaneous emphysema and obesity make the exam harder. A pericardial effusion can decompress into the pleura through a pericardial injury, and the pericardial exam may look normal while blood accumulates in the chest. Therefore, a large hemothorax in a wound near the heart should not be reassured by a pericardium without fluid.

The chest drain and reading the output

Most penetrating chest wounds that arrive alive at the hospital are treated with chest drainage and observation. The drain decompresses the pneumothorax, removes the blood, allows the lung to re-expand and, at the same time, works as a monitor of bleeding. The volume drained soon after insertion and the rate at which the bottle keeps filling say a lot about the source of the blood.

Pulmonary bleeding usually decreases when the lung re-expands, because the parenchyma is supplied under low pressure and re-expansion compresses the injured vessels. Bleeding from intercostal arteries, the internal mammary artery, the heart or the great vessels tends to continue. That is why output is read over time, and not only in the first minute.

Some practical precautions help with reading:

• Record the volume drained soon after insertion.
• Note the volume every hour, or at shorter intervals if the patient is unstable.
• Check that the drain is patent, because a clotted drain can give a false impression that bleeding has stopped.
• Repeat imaging to look for retained hemothorax.
• Correlate the output with hemodynamics and with the need for transfusion.

The position of the drain also matters. A poorly positioned drain, kinked or with the last hole outside the pleural cavity, drains poorly and can cause subcutaneous emphysema. The radiograph after insertion confirms the position and shows whether the lung has re-expanded. When the hemithorax remains opaque despite a well-positioned drain, the blood may be clotted or the drain obstructed, and tomography helps clarify.

These precautions avoid two opposite errors: operating on pulmonary bleeding that was already stopping and waiting too long for arterial bleeding that will not stop on its own.

When the output indicates surgery

The drainage criteria for thoracotomy are relatively stable across sources. In a Dutch trauma center, the indications for thoracotomy included hemothorax on radiography with initial drain output above 1,500 mL or continuous output above 200 mL per hour for 2 to 4 hours after insertion, and also smaller hemothorax with CT angiography findings that indicated surgery (Van Waes et al., 2012). The review by Cakmak et al. describes a similar criterion: initial drainage above 1,500 mL or continuous drainage above 200 mL per hour for 2 to 3 hours, with a limit of 150 mL per hour in older adults (Cakmak et al., 2022).

Situation	Criterion described	Source
Initial drain output	Above 1,500 mL	Van Waes et al.; Cakmak et al.
Continuous output	Above 200 mL per hour for 2 to 4 hours	Van Waes et al.
Continuous output in older adults	Above 150 mL per hour	Cakmak et al.
Tamponade with systolic pressure above 60 mmHg	Thoracotomy or sternotomy in the operating room	Van Waes et al.
Tamponade with systolic pressure below 60 mmHg or loss of signs of life in the hospital	Thoracotomy in the emergency room	Van Waes et al.
Massive air embolism	Immediate thoracotomy	Van Waes et al.

The numbers are guides, not absolute rules. A patient who drains 1,200 mL but remains hypotensive despite transfusion may need surgery before reaching the limit. A patient who drains 1,600 mL at once and then stops bleeding, with stable hemodynamics, may be observed in some services. The decision integrates output, hemodynamics, response to transfusion and trajectory. The text on clinical decision-making discusses this type of integrated reasoning.

Cardiac injury and tamponade

Penetrating cardiac injury is one of the most lethal in trauma. A review on the topic notes that up to 94 in every 100 patients with penetrating cardiac injury die at the scene, and that mortality among those who reach the trauma center with signs of life ranges from 17 to 58 in every 100 (Chestovich et al., 2018). The projectile usually causes larger injuries than a knife, and this shows in the numbers.

In a series of 240 patients with penetrating cardiac trauma in Bogotá, overall mortality was 14.6 in every 100: 11.7 in every 100 in stab wounds and 41.2 in every 100 in gunshot wounds. On arrival, 67 in every 100 had tamponade, and among them mortality was 54.5 in every 100 in gunshot wounds versus 18 in every 100 in stab wounds (Isaza-Restrepo et al., 2017).

Tamponade happens quickly because the normal pericardium accommodates only 100 to 250 mL of blood acutely. As the pressure inside the pericardium rises, cardiac output falls progressively (Lateef Wani et al., 2012). Paradoxically, tamponade can temporarily contain the bleeding from the cardiac injury and buy time for definitive treatment. The same review notes that small injuries with tamponade can be treated with pericardiocentesis, but this is an exceptional measure.

The review by Lee et al. gives an important warning: intubation and positive pressure ventilation reduce venous return to the right atrium and can lead a patient with tamponade to cardiac arrest (Lee et al., 2023). Whenever possible, anesthetic induction takes place with the surgeon ready to open the chest.

Not every pericardial effusion in a stable patient requires sternotomy. One trauma center adopted selective pericardial window, lavage and drainage for stable patients with pericardial fluid on ultrasound. Of the 37 who underwent pericardial window, 21 had hemopericardium: 16 went on to sternotomy and 5 were treated with drainage alone, with drains removed on average on the third or fourth postoperative day (Chestovich et al., 2018).

Resuscitative thoracotomy

Thoracotomy in the emergency room is a last-resort procedure, performed in patients in arrest or near arrest. It allows evacuation of tamponade, direct control of intrathoracic hemorrhage, treatment of massive air embolism, open cardiac massage and clamping of the descending aorta to redistribute flow (Van Waes et al., 2012).

The results depend on the mechanism and on the signs of life. A systematic review of resuscitative thoracotomies at European centers gathered 376 procedures. Overall survival was 42.8 in 100, with 61.2 in 100 in penetrating trauma and 25.4 in 100 in blunt trauma. Survival of thoracotomies performed in the emergency room for penetrating trauma was 41.6 in 100 (Narvestad and colleagues, 2016).

The signs of life weigh heavily. In a Norwegian cohort of 31 patients with penetrating cardiac injury, the 13 who arrived with signs of life survived. Of the 18 who arrived without signs of life and underwent thoracotomy in the emergency room, the 8 who already had no signs of life at the scene died, and of the remaining 10 one survived (Kaljusto and colleagues, 2015). In the Dutch series, witnessed loss of signs of life was accompanied by mortality of 100 in 100 (Van Waes and colleagues, 2012).

A narrative review on penetrating cardiac injury describes the signs of life as follows (Hromalik and colleagues, 2023):

• Pupillary reaction.
• Spontaneous ventilation.
• Carotid pulse present.
• Measurable or palpable blood pressure.
• Limb movement.
• Cardiac electrical activity.

The same review cites the strong recommendation for thoracotomy in patients who arrive without a pulse but with signs of life after penetrating thoracic trauma (Hromalik and colleagues, 2023). The review by Lee and colleagues mentions resuscitative thoracotomy in patients without a pulse with resuscitation for less than 15 minutes, usually by left anterolateral thoracotomy (Lee and colleagues, 2023).

Airway, video-assisted thoracoscopy and retained hemothorax

While the surgical decision is made, resuscitation continues in parallel. In the patient who is bleeding, the priority is to replace blood and blood products in a balanced way, avoid large volumes of crystalloid, correct hypothermia and acidosis and treat coagulopathy. Many services use massive transfusion protocols, activated early, that release packed red blood cells, plasma and platelets in defined proportions. The pressure target is usually lower than usual until bleeding is controlled, except when there is associated brain injury. These details depend on each institution's protocol, but the principle is the same: buy time until surgical hemostasis.

Analgesia is also part of the care. Pain from the wound and from the drain limits deep breathing and coughing, favoring atelectasis and pneumonia. Adequate analgesia, respiratory physiotherapy and early mobilization help the lung to re-expand and reduce complications in the following days.

Tracheal or bronchial injury may present with extensive subcutaneous emphysema, a pneumothorax that does not re-expand and persistent air leak through the drain. The review by Cakmak and colleagues describes that multidetector tomography has a sensitivity of 94 in 100 for tracheobronchial injuries (Cakmak and colleagues, 2022). Bronchoscopy confirms the injury and helps position the tube, sometimes with selective intubation of the healthy lung.

In the stable patient, video-assisted thoracic surgery has gained ground. In an Italian series, 13 stable patients with penetrating thoracic wounds were explored by video-assisted thoracoscopy, which identified 5 diaphragm injuries, 3 intercostal artery injuries and 1 diaphragmatic artery injury. The authors concluded that the technique is safe and effective for diagnosing and treating these injuries, reducing missed injuries, and useful in treating retained hemothorax and persistent air leak (Paci and colleagues, 2006). Unstable patients and those with hemothorax above 1,500 mL associated with instability were excluded from the series.

Retained hemothorax, clotted blood that the drain cannot remove, increases the risk of empyema and of pulmonary entrapment. The same series notes that late treatment of retained hemothorax and persistent air leak increases morbidity, length of stay and chronic sequelae (Paci and colleagues, 2006). Diaphragm injury, especially on the left, can go unnoticed and present months later as a hernia.

Complications of the chest drain

Chest drains save lives, but they are not harmless. A broad review of the procedure recalls that injuries to abdominal and thoracic organs, fistulas and vascular injuries are among the most serious complications, while recurrent pneumothorax, infection at the insertion site and a misplaced or non-functioning drain are the most common and also increase morbidity and cost (Kwiatt et al., 2014).

Empyema deserves special attention in penetrating trauma. According to the authors, it is more frequent after a penetrating wound than after blunt trauma, because the wound itself carries microorganisms straight to the pleura. Prolonged time with the drain, a long stay in intensive care, pulmonary contusion, laparotomy and retained hemothorax are associated with the condition, and Staphylococcus aureus is the most frequent agent (Kwiatt et al., 2014). Antibiotic prophylaxis before drainage remains controversial, and the decision follows the local protocol (Kwiatt et al., 2014).

A hemothorax that is not well drained can progress to fibrothorax. The review describes that the process can begin one to two weeks after the injury, with dyspnea in the awake patient and increasing difficulty ventilating in the intubated patient. Once fibrothorax sets in, treatment is surgical, with removal of the clot and adhesions and, sometimes, formal decortication. That is why the authors insist that retained hemothorax be emptied before it causes fibrosis (Kwiatt et al., 2014).

Removing the drain also carries risk. Pneumothorax can return if the tube comes out before full reexpansion of the lung, if there is an occult air leak or if air enters through the pleura at the moment of removal, which calls for imaging after the procedure (Kwiatt et al., 2014). For anyone reasoning about the case, new dyspnea or fever days after drainage are clues that call for reassessment.

How NEXO helps train this reasoning

Training with fictional clinical cases helps you recognize patterns before you meet them on shift, as long as each clue is read calmly and compared with the hypotheses that are still open. In chest trauma, the clues can include vital signs, auscultation findings, imaging and course, and the challenge is to notice, for example, when a picture that looked like hemothorax is actually tamponade. The text on differential diagnosis with clues shows how to organize this reasoning.

The texts on diagnostic uncertainty and on hemorrhage control and the MARCH sequence also help. To understand points and rewards, see the NEXO economy page. There are also tracks for those who research (Researcher), for those who review cases (Curator), for those who produce content (Creators) and for those who want to follow results (Closer).

Frequently asked questions

Does every gunshot wound to the chest need surgery?

No. Many patients are treated with chest drainage and observation. Surgery is indicated for instability, high drain output, tamponade, injury to great vessels, the airway or the esophagus, and for complications such as retained hemothorax.

Why 1,500 mL?

It is a classic threshold that indicates voluminous bleeding, probably from a source that will not stop on its own. Continuous output above 200 mL per hour for a few hours has the same meaning. The numbers guide, but the decision also considers hemodynamics and the response to transfusion.

Is Beck's triad still useful?

It describes the physiology of tamponade, but it is poorly sensitive in the emergency room, where noise interferes with auscultation and hypovolemia hides jugular distension. Bedside ultrasound is today the main tool.

When does emergency room thoracotomy make sense?

Mainly in penetrating trauma, especially cardiac, in patients who lost their pulse shortly before or during care and still show signs of life. Without signs of life since the scene, outcomes are very poor.

Why is intubating a patient with tamponade risky?

Because positive pressure ventilation reduces venous return to an already compressed heart and can precipitate cardiac arrest. Whenever possible, induction happens with the team ready to open the chest.

What should be done when the wound is below the nipple?

Think about thoracoabdominal injury. The diaphragm rises on expiration and can be hit by wounds that seem only thoracic. Abdominal ultrasonography, CT in the stable patient and, in many services, laparoscopy or video-assisted thoracoscopy help look for injury to the diaphragm, liver, spleen and stomach.

Does the projectile retained in the lung need to be removed?

Most of the time, not in the acute phase. Removal is considered when the projectile is inside a vessel or the heart, migrates, causes infection, recurrent bleeding or symptoms. The decision is individual and is usually made after stabilization.

Take-home messages

• Actively look for tension pneumothorax, massive hemothorax and tamponade.
• Use bedside ultrasonography without being reassured by a normal pericardium in the face of a large hemothorax.
• Record drain output at insertion and every hour.
• Consider thoracotomy with initial output above 1,500 mL or continuous output above 200 mL per hour.
• Remember that positive pressure ventilation can precipitate arrest in tamponade.
• Reserve resuscitative thoracotomy for those with signs of life, especially in penetrating trauma.
• Look for retained hemothorax and diaphragm injury at follow-up.

If you like reasoning from clues, today's case is waiting on the NEXO home page.

References

1. Cakmak G, Cansun F, Saracoglu A, et al. Airway management in penetrating thoracic trauma. Anaesthesiol Intensive Ther. 2022. PMID 36000693.
2. Chestovich PJ, McNicoll CF, Fraser DR, et al. Selective use of pericardial window and drainage as sole treatment for hemopericardium from penetrating chest trauma. Trauma Surg Acute Care Open. 2018. PMID 30234166.
3. Heydari F, Esmailian M, Dehghanniri M. Diagnostic Accuracy of Ultrasonography in the Initial Evaluation of Patients with Penetrating Chest Trauma. Emerg (Tehran). 2014. PMID 26495352.
4. Hromalik LR, Wall MJ, Mattox KL, et al. Penetrating cardiac injury: a narrative review. Mediastinum. 2023. PMID 37261091.
5. Isaza-Restrepo A, Bolívar-Sáenz DJ, Tarazona-Lara M, et al. Penetrating cardiac trauma: analysis of 240 cases from a hospital in Bogota, Colombia. World J Emerg Surg. 2017. PMID 28616061.
6. Kaljusto ML, Skaga NO, Pillgram-Larsen J, et al. Survival predictor for penetrating cardiac injury; a 10-year consecutive cohort from a scandinavian trauma center. Scand J Trauma Resusc Emerg Med. 2015. PMID 26032760.
7. Kwiatt M, Tarbox A, Seamon MJ, et al. Thoracostomy tubes: A comprehensive review of complications and related topics. Int J Crit Illn Inj Sci. 2014. PMID 25024942.
8. Lateef Wani M, Ahangar AG, Wani SN, et al. Penetrating cardiac injury: a review. Trauma Mon. 2012. PMID 24829887.
9. Lee A, Hameed SM, Kaminsky M, et al. Penetrating cardiac trauma. Surg Open Sci. 2023. PMID 36466048.
10. Narvestad JK, Meskinfamfard M, Søreide K. Emergency resuscitative thoracotomy performed in European civilian trauma patients with blunt or penetrating injuries: a systematic review. Eur J Trauma Emerg Surg. 2016. PMID 26280486.
11. Paci M, Ferrari G, Annessi V, et al. The role of diagnostic VATS in penetrating thoracic injuries. World J Emerg Surg. 2006. PMID 17022807.
12. Swaroop M, Straus DC, Agubuzu O, et al. Pre-hospital transport times and survival for Hypotensive patients with penetrating thoracic trauma. J Emerg Trauma Shock. 2013. PMID 23494152.
13. Van Waes OJ, Van Riet PA, Van Lieshout EM, et al. Immediate thoracotomy for penetrating injuries: ten years' experience at a Dutch level I trauma center. Eur J Trauma Emerg Surg. 2012. PMID 23162671.