chest tube, blood should be slowly evacuated from the pleural space Blood within the pleural cavity may tamponade a significant bleeding source within the chest and evacuating that blood may cause new bleeding to occur Patients can exsanguinate rapidly, which is why IV access, adequate volume resuscitation, and blood available for transfusion should be priorities Thoracostomy drainage needs to be closely monitored Large ongoing blood loss from a chest tube should be collected in a system that allows autotransfusion Thoracotomy Thoracotomy is indicated for bleeding that continues at a rate of greater than to mL/kg/hr, inability to expand the lung, or retained blood within the pleural cavity Failure to adequately drain a hemothorax may lead to restrictive lung disease from a fibrothorax or an empyema from the clotted material becoming infected Disposition All patients with a traumatic pneumothorax or hemothorax require admission to the hospital If the pneumothorax is small and the patient is asymptomatic, hospital observation and passive administration of oxygen via a nonrebreather mask is all that is necessary A small pneumothorax is classically described as being less than 15% of the hemithorax, although it is common to underestimate the size of a pneumothorax using plain films An asymptomatic patient may rapidly become symptomatic if a small, simple pneumothorax progresses to a large or tension pneumothorax; therefore, even asymptomatic patients with a traumatic pneumothorax should be admitted to the hospital for observation Patients with chest tubes should be hospitalized on a unit that is capable of monitoring and troubleshooting the tube and the collection device An unstable airway, respiratory distress, severe hypoxia, ongoing blood loss, and presence of other severe injuries are among the indications for admission to an intensive care unit PULMONARY CONTUSIONS CLINICAL PEARLS AND PITFALLS