Traumatic Hemothorax and Same-Side Central Venous Access

A 35-yr-old woman is admitted to the emergency room after attempting suicide by jumping from a bridge. She is in severe pain, but orientated for time and place. Her heart rate is 120 beats/min and her BP 85/40. She is breathing 100% oxygen through a nonrebreathing mask with safety vent. (Hudson RCI, Temecula, CA) and her oxygen saturation is 96%. She has multiple fractures, including pelvis, right humerus, 9th thoracic vertebra, and ribs 6–10 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 A cordis catheter (PSI kit; Arrow International, Inc., Reading, PA) is inserted and blood is easily withdrawn for chemical analysis, internal normalized ratio (INR), and cross matching for 6 units of red blood cells. After inserting the right chest drain, 1,500 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 Fluidsystem warmer 1000 (Level 1 Technologies, Rockland, MA). The emergency room staff is concerned because despite continuous volume replacement with 3 liters 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. You place two additional cannulae into the right internal jugular and right femoral veins. Blood is easy withdrawn from both catheters. You attach the subclavian vein to a CVP monitor, which again shows a value of zero and fluctuates with respiration. More blood is given through the new large-bore catheters and the patient seems to stabilize. Dark blood is still draining out of the right chest drain but at a slower rate. The laboratory reports that the international normalized ratio (INR) is 2.3. The surgeon orders fresh frozen plasma. You are still looking at the dark blood coming out of the chest drain and wondering about the increased INR, as clinically she does not seem to be oozing. You send off a repeat INR. The surgeon is keen to start the operation and you agree reluctantly, but you feel there is something wrong. Why are you concerned?


Methylene Blue International Normalize Ratio Central Venous Pressure Subclavian Vein Pleural Space 
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