From the University of Ottawa (R.W.G., A.M.F., L.P., A.T.); and Trauma Services, Division of General Surgery (R.W.G., A.M.F., A.T., J.L.), Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.
J Trauma Acute Care Surg. 2020 Dec;89(6):1225-1232. doi: 10.1097/TA.0000000000002936.
Hemothorax is a common sequelae following thoracic trauma and is associated with significant morbidity and mortality. Current guidelines recommend all traumatic hemothoraces be considered for drainage with tube thoracostomy (TT), regardless of size. With increasing use of computed tomography, smaller hemothoraces not seen on x-ray (defined as an occult hemothorax) are frequently detected.
This systematic review was performed to gather data on patients with occult hemothorax managed with TT or without TT (termed expectant management [EM]). MEDLINE, EMBASE, and Cochrane databases from inception to October 2019 were searched for relevant articles. The primary outcome was rates of failure of expectant (conservative) management. Secondary outcomes of interest included predictors of TT insertion, predictors of failure of EM, and morbidity and mortality in patients with occult hemothorax.
We screened 1,329 abstracts from which 6 articles reporting 1,405 patients with occult hemothorax were included. Of these patients, 601 (43.68%) were managed initially with TT, and 802 (56.32%) were managed expectantly. Of the 802 patients managed expectantly, 212 failed conservative management and underwent TT insertion (23.1% pooled failure rate estimate [95% confidence interval, 17.1-29.1%]). The presence of concomitant pneumothorax predicted upfront TT insertion. Of the patients who failed EM, the need for mechanical ventilation and the presence of a large hemothorax predicted failure. Mortality was similar in both groups.
Conservative treatment of occult hemothorax fails in 23.1% of patients. The presence of hemothorax greater than 300 mL and the need for mechanical ventilation predicted failure of conservative treatment and the need for TT. There was no difference in mortality between EM and TT cohorts. These data suggest that it may be possible to safely observe patients with occult hemothoraces less than 300 mL (1.5 cm pleural stripe) secondary to blunt trauma without upfront TT insertion.
Systematic review and meta-analysis, level III.
血胸是胸部创伤的常见后遗症，与显著的发病率和死亡率相关。目前的指南建议所有创伤性血胸都应考虑进行引流，使用胸腔引流管（TT），无论其大小如何。随着计算机断层扫描的广泛应用，在 X 光片上看不到的较小血胸（定义为隐匿性血胸）经常被检测到。
本系统评价旨在收集有关隐匿性血胸患者接受 TT 或不接受 TT（称为保守治疗[EM]）治疗的数据。从创建到 2019 年 10 月，在 MEDLINE、EMBASE 和 Cochrane 数据库中搜索相关文章。主要结局是保守（姑息）治疗失败的发生率。次要结局包括 TT 插入的预测因素、EM 失败的预测因素以及隐匿性血胸患者的发病率和死亡率。
我们筛选了 1329 篇摘要，其中纳入了 6 篇报告了 1405 例隐匿性血胸患者的文章。这些患者中，601 例（43.68%）最初接受 TT 治疗，802 例（56.32%）接受保守治疗。在 802 例接受保守治疗的患者中，有 212 例保守治疗失败并接受 TT 插入（23.1%的汇总失败率估计值[95%置信区间，17.1-29.1%]）。合并气胸的存在预测了 TT 的早期插入。在 EM 失败的患者中，需要机械通气和存在大量血胸预测了治疗失败。两组的死亡率相似。
在 23.1%的隐匿性血胸患者中，保守治疗失败。血胸大于 300 mL 和需要机械通气预测了保守治疗失败和 TT 的需要。在 EM 和 TT 队列之间，死亡率没有差异。这些数据表明，对于钝性创伤导致的小于 300 毫升（1.5 厘米胸膜条纹）的隐匿性血胸患者，可能可以安全地不进行 TT 插入，而进行观察。
系统评价和荟萃分析，III 级。
