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Validation of a safe volumetric cut-off for observation of traumatic hemothorax: A Western Trauma Association
Anna Tatakis1, Danielle Wilson, Abdul Hafiz Al Tannir
1Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin (A.T., D.W., J.A., K.B., J.B., M.d.M.); Department of Surgery, New Mexico School of Medicine, Albuquerque, New Mexico (A.H.Al. T.); Department of Surgery, Emory University School of Medicine, Atlanta, Georgia (J.D.S., K.C.); R Adams Cowley Shock Trauma Center and the Shock Trauma Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, Maryland (J.J.K., R.A.K.); Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee (E.O.Y., A.M.); Department of Surgery, Mission Hospital, Asheville, North Carolina (T.K., A.S.); Department of Surgery, Cooper University Hospital, Camden, New Jersey (K.E.-R., I.B.F.); Department of Surgery, Yale School of Medicine, New Haven, Connecticut (J.C., A.W.); Department of Surgery, Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, Minnesota (D.S., M.A.C., K.W.); Department of Surgery, Mount Sinai Hospital, Chicago, Illinois (G.C., M.F.); Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, La Jolla, California (L.V.H., A.E.B.); Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania (P.N.); Department of Surgery, UCHealth Medical Center of the Rockies, Loveland, Colorado (B.N., B.S.); Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania (M.F., K.O.); Trunkey Center for Civilian and Combat Casualty Care, Oregon Health & Science University, Portland, Oregon (A.M.); School of Medicine, Oregon Health & Science University, Portland, Oregon (J.M.); Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California-Davis, Sacramento, California (S.S., C.C.); 60 Medical Group, Travis AFB, Fairfield, California (S.S.); Department of Surgery, Medical City Plano Hospital, Plano, Texas (E.K., D.L.).
Background:
Traumatic hemothorax (HTX) contributes significantly to trauma morbidity and is frequently managed with tube thoracostomy (TT). However, TT placement has complications and some HTXs can be successfully observed. Optimal observation criteria remain unclear, and management practices vary. This multicenter study aimed to characterize current practices, determine observation failure rates, and identify predictors of safe observation.
Methods:
We conducted a prospective observational study from July 2023 to June 2025 across 16 trauma centers. Adult patients with computed tomography-confirmed HTX were included. Exclusions included age under 18 years, TT before computed tomography, concurrent pneumothorax >35 mm, death within 48 hours, or observation failure due to operative intervention. HTX volume was calculated using Mergo's formula (V=d2×L). Each hemithorax was analyzed independently. The primary outcome was observation failure. HTX >300 mL was evaluated as a predictor of failure in a multivariable logistic regression model.
Results:
Among 962 HTXs in 932 patients, 68% (n=657) were initially observed. The observation group had shorter hospital (7 vs. 9 d) and intensive care unit stays (1 vs. 3 d) compared with immediate TT (p<0.001). Observation failure rate was 22% (n=141), most commonly from HTX progression (54%). Failed observation patients had longer hospital stays (13 vs. 9 d, p<0.001) but similar complication rates, secondary intervention needs, and 30-day outcomes compared with early TT. HTX volume >300 mL strongly predicted observation failure (adjusted odds ratio, 16.01; 95% confidence interval, 8.25-31.06). Management practices varied: 52% received antibiotics with TT, 16% underwent irrigation, and thoracostomy tube sizes ranged from 8 to 36 Fr.
Conclusions:
Initial observation of HTX is frequently successful, with HTX volume >300 mL being the strongest predictor of failure. Failed observation patients experience longer stays but similar outcomes to early TT placement. Notable practice variation highlights opportunities for research and standardization through unified practice management guidelines. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
Level Of Evidence:
Therapeutic/Care Management; Level III.
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