eComment. Prompt decision making on the site of surgical approach in patients with chest trauma-a brief communication

We read with great interest the article by Chen et al. [1]. Haemothorax is an important finding in trauma patients, which may either be a self-limited condition or the evidence of a life-threatening injury to the thoracic or abdominal organs. We have encountered an extremely rare case of type B dissection in which the first finding was a right-sided haemothorax [2]. Considering the case presented by Chen et al., we would like to figure out the importance of the type and site of the surgical incision. In our experience, if the echocardiography does not reveal any significant cardiac injury or pericardial effusion in such a trauma patient, the easiest and safest approach is a lateral thoracotomy at the fifth intercostal space. This approach helps discriminate intra- and extra-thoracic etiologies of bleeding in such a patient. In case of a cardiac laceration or cardiopulmonary arrest, access to the heart or cannulation of the aorta and right atrium for the utilization of cardiopulmonary bypass is easy with or without a hemi-clamshell extension of the incision. The presented case could be a major pulmonary vessel branch or intercostal artery injury leading to massive right haemothorax in which the subxiphoid pericardial window or a full sternotomy will have a limited use, but a waste of time during an active bleeding. Even the cause of the right haemothorax is a cardiac injury; an uncontrolled subxiphoid access may lead to acute decompression and cardiopulmonary arrest as presented in this case. In this patient, considering the negative echocardiographic findings for a significant pericardial effusion, the mentioned surgical algorithm does not target the most frequent causes of a massive right haemothorax. In such cases we prefer a lateral thoracotomy with a hemi-clamshell extension towards midline when necessary. Such patients require prompt evaluation and surgical intervention is lifesaving in most of the cases.