ICU · Trauma
Massive haemothorax and emergency thoracotomy (resuscitative)
Also known as Massive haemothorax · Emergency thoracotomy · Resuscitative thoracotomy · Emergency department thoracotomy · EDT · Clamshell thoracotomy · Trauma thoracotomy
Massive haemothorax: 1500 mL blood in pleural space OR 200 mL/hr ongoing drainage. Life-threatening: impairs ventilation + circulation (hypovolaemia + tension physiology). Management: IMMEDIATE large-bore chest tube (28-32 Fr; 36-40 Fr offers no advantage) at 5th ICS mid-axillary line. Resuscitative thoracotomy (EDT / clamshell): emergency department procedure for arrested/peri-arrest trauma — releases tamponade, controls bleeding, open cardiac massage, cross-clamps aorta. INDICATIONS: penetrating thoracic trauma with arrest <15 min (EAST strong recommendation with signs of life); penetrating extrathoracic trauma and blunt trauma with signs of life (conditional); blunt trauma without signs of life — recommend against. Survival: penetrating 8.8% (stab 16.8%, gunshot 4.3%), blunt 1.4% (Rhee 2000); pulseless penetrating thoracic with signs of life 21.3% (EAST 2015).
Checked against its sources on 2 Sept 2026
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
CICMFFICMEDIC
Red flags
- Massive haemothorax: >1500 mL initial OR >200 mL/hr ongoing → thoracotomy
- Resuscitative thoracotomy: penetrating chest trauma + arrest <15 min → immediate
- Blunt trauma arrest >15 min, no signs of life → thoracotomy futile
- Survival: penetrating stab 16.8%, gunshot 4.3%, blunt 1.4% (Rhee 2000); penetrating thoracic with SOL 21.3% (EAST 2015)
[7]
[9]
[12]
[7]
[8]
[9]
Resuscitative thoracotomy — EAST practice management guideline (2015): patient selection and survival
[9]
[13]
[10]| Scenario (pulseless on presentation) | EAST recommendation | Survival (neurologically intact) |
|---|---|---|
| Penetrating thoracic injury, signs of life present | YES — strong recommendation | 21.3% (11.7%) |
| Penetrating thoracic injury, no signs of life | Conditional | 8.3% (3.9%) |
| Penetrating extrathoracic injury, signs of life present | Conditional | 15.6% (16.5%) |
| Penetrating extrathoracic injury, no signs of life | Conditional | 2.9% (5.0%) |
| Blunt injury, signs of life present | Conditional (selective) | 4.6% (2.4%) |
| Blunt injury, no signs of life | NO — recommend against | 0.7% (0.1%) |
References21ShowHide
- [7]Boersma WG, Stigt JA, Smit HJ, et al. Treatment of haemothorax Respir Med, 2010.PMID 20817498
- [8]Hulsebos H, Bernard J Consider Autotransfusion in the Field Mil Med, 2016.PMID 27483539
- [9]Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the Eastern Association for the Surgery of Trauma J Trauma Acute Care Surg, 2015.PMID 26091330
- [10]Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years J Am Coll Surg, 2000.PMID 10703853
- [11]Tesoriero R, Coimbra R, Biffl WL, et al. Adult emergency resuscitative thoracotomy: A Western Trauma Association clinical decisions algorithm J Trauma Acute Care Surg, 2024.PMID 39451159
- [12]Dewey MG, Moore EE, Sauaia A, et al. Resuscitative thoracotomy: What you need to know J Trauma Acute Care Surg, 2026.PMID 41417726
- [13]Slessor D, Hunter S To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis Ann Emerg Med, 2015.PMID 25443990
- [14]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203
- [15]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [16]Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial Lancet, 2011.PMID 21439633
- [17]Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg, 2012.PMID 22006852
- [18]Meyer DM, Jessen ME, Wait MA, et al. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial Ann Thorac Surg, 1997.PMID 9386710
- [19]Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma J Trauma Acute Care Surg, 2012.PMID 22327984
- [20]Jansen JO, Hudson J, Cochran C, et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial JAMA, 2023.PMID 37824132
- [21]Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma J Trauma Nurs, 2015.PMID 25768967
- [22]García A, Millán M, Ordoñez CA, et al. Damage control surgery in lung trauma Colomb Med (Cali), 2021.PMID 34188322
- [23]Martin MJ, Brasel KJ, Brown CVR, et al. Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm J Trauma Acute Care Surg, 2023.PMID 37337331
- [24]Quinn N, Palmer CS, Bernard S, et al. Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia Emerg Med Australas, 2020.PMID 31531952
- [25]Broderick SR Hemothorax: Etiology, diagnosis, and management Thorac Surg Clin, 2013.PMID 23206720
- [26]Waters JH Cell salvage in trauma Curr Opin Anaesthesiol, 2021.PMID 34074882
- [27]Bresgen TU, Salinaro F, Barcella B, et al. Acute pain management of rib fractures: a narrative review Injury, 2025.PMID 41223579