• Intravenous fluid resuscitation keeping in mind that blood loss should preferably be replaced with blood. Always insert two wide bore IV cannulae in these patients.
  • Appropriate use of blood and blood products. Think about activating the Major Haemorrhage Protocol (MHP).
  • Insert  a chest drain, connecting the drain to a cell salvage/saver machine for autotransfusion purposes (image right – Fig 10: Cell salvage/saver machine). If a cell saver is not readily available then prepare the usual drainage apparatus, but prime the underwater seal with saline not sterile water. The saline/blood collection can still be run through a cell saver later.
  • Occasionally a massive haemothorax may be well tolerated, typically in young patients with a chest stabbing.  Delaying chest drain insertion until reaching thoracic theatre, where cell salvage exists, is an option.
  • Whilst a guideline for thoracotomy exists (see table below), have a low threshold for engaging thoracic surgeons early.
ATLS indications for thoracotomy [2]
  • Prompt drainage of 1500 ml blood, or a third of the patient’s circulating volume
  • >200 ml/hr blood loss for 2-4 hrs
  • Continued need for blood transfusion