Case 35: Traumatic Hemothorax and Same-side Central Venous Access

Abstract

A 35-year-old woman is admitted to the emergency room after attempting suicide by jumping from a bridge. She is in severe pain, orientated for time and place. Her heart rate is 120 bpm and her BP 85/40. She is breathing 100% oxygen through a non-rebreathing mask with safety vent (Hudson RCI, Temecula, CA, USA), and her oxygen saturation is 96%. She has multiple fractures, including the pelvis, right humerus, ninth thoracic vertebra, and ribs 6 through 10 on the right side. She has a right-sided hemothorax. The right subclavian vein is cannulated using the infraclavicular approach and the Seldinger technique. A cordis catheter (PSI kit, Arrow International, Inc. Reading. PA 19605, USA) is inserted into the vein, and blood is easily withdrawn for chemical analysis. These include INR and cross matching for 6 units of red blood cells. After inserting the right chest drain, 1500 ml of blood is drained rapidly without any ill effects. A new chest x-ray shows complete resolution of the hemothorax, and the subclavian catheter is seen in the correct place. The central venous pressure (CVP) is zero and fluctuates with respiration. Blood arrives and 4 units of packed red cells are given rapidly through the subclavian vein via a Level 1 Fluid-system warmer 1000 (Level 1 Technologies, Rockland, MA 02370). The emergency room staff is concerned because despite continuous volume replacement with 3 l of crystalloids and albumin 250 ml ×4 through a 16-gauge IV catheter in her right hand, her blood pressure deteriorates, and increased drainage of dark blood is seen from the chest drain. A diagnosis of laceration of major vessels in the chest is made, and you are called to anesthetize this patient for a right thoracotomy.