# Situation: The emergency department receives three adults injured in a collision between a passenger van and a truck. Each is seen by a separate team, and the nurse is assigned to monitor all three. The first client has a right hemothorax, and a chest tube has been inserted. The nurse is shown four drainage records from clients in the unit with the same injury. The records are from blunt chest trauma, and the unit follows Advanced Trauma Life Support thresholds. Which record meets the criteria for surgical exploration?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630140  
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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: The emergency department receives three adults injured in a collision between a passenger van and a truck. Each is seen by a separate team, and the nurse is assigned to monitor all three.

The first client has a right hemothorax, and a chest tube has been inserted. The nurse is shown four drainage records from clients in the unit with the same injury. The records are from blunt chest trauma, and the unit follows Advanced Trauma Life Support thresholds. Which record meets the criteria for surgical exploration?

## 보기

1. Initial 700 mL; then 210, 220, and 230 mL each hour **✔ 정답**
2. Initial 1,100 mL; then 110, 90, and 80 mL each hour
3. Initial 400 mL; then 180, 190, and 190 mL each hour
4. Initial 1,350 mL; then 60, 40, and 30 mL each hour

**정답: 1**

## 해설

Surgical exploration (thoracotomy) is indicated by an initial chest tube drainage of 1,500 mL or more, or by drainage of 200 mL/hour or more for 2–4 hours, or by an ongoing need for transfusion. Only the record with 210, 220, and 230 mL/hour for 3 hours meets a criterion; none of the initial volumes reaches 1,500 mL.

## 심화 해설

The question asks which chest tube drainage record meets the criteria for surgical exploration in a client with blunt chest trauma. The decision to move from observation or tube thoracostomy to thoracotomy is based on volume and rate of blood loss, because these reflect whether bleeding is ongoing or has already tamponaded.

Interpreting the drainage records

The key principle is that a single large initial output can represent evacuation of blood that had already accumulated in the pleural space before the tube was placed. That blood may not indicate active, ongoing hemorrhage. In contrast, persistent high output after initial drainage is the more reliable sign of continued bleeding, because the pleural space has already been emptied and any further large volume represents fresh blood loss.

The threshold used in this scenario is 200 mL/hour or more for 2–4 hours. An initial output of 1,500 mL or more would also qualify, but none of the records reaches that volume.

| Record | Initial output | Hourly outputs after initial | Meets 200 mL/hr for 2–4 hr? | Meets 1,500 mL initial? | Decision |
| --- | --- | --- | --- | --- | --- |
| 1 | 700 mL | 210, 220, 230 mL | Yes — 3 consecutive hours above 200 mL | No | Surgical exploration |
| 2 | 1,100 mL | 110, 90, 80 mL | No — all below 200 mL | No | Continue monitoring |
| 3 | 400 mL | 180, 190, 190 mL | No — all below 200 mL | No | Continue monitoring |
| 4 | 1,350 mL | 60, 40, 30 mL | No — all below 200 mL | No | Continue monitoring |

Record 1 is the only one that satisfies a surgical criterion. The initial 700 mL is below the massive hemothorax threshold, but the subsequent three hours of 210, 220, and 230 mL each hour demonstrate that bleeding is not slowing down. Watch out! Record 4 has a much larger initial volume of 1,350 mL, which can look alarming, but the hourly outputs drop sharply to 60, 40, and 30 mL. That pattern suggests the initial large volume was accumulated blood, and the bleeding has largely stopped. Record 2 also has a large initial volume of 1,100 mL, but the hourly outputs are all well below 200 mL.

Why ongoing drainage rate matters more than initial volume

The pleural space can hold a substantial volume of blood. When a chest tube is first inserted, it drains whatever blood has already collected there. That initial volume reflects the cumulative injury up to that point, not necessarily the current rate of bleeding. The hourly output after the initial drainage reflects active bleeding, because the pleural space has been decompressed and any new blood must come from ongoing hemorrhage.

This distinction is clinically important because thoracotomy is a major intervention with significant morbidity. A client whose bleeding has stopped does not need surgery even if the initial drainage was large. A client whose bleeding continues at a high rate despite chest tube decompression is at risk for hemodynamic instability, persistent hemorrhagic shock, and the development of a clotted hemothorax or retained hemothorax that can later organize into fibrothorax.

Pathophysiology of ongoing hemothorax

Blunt chest trauma can lacerate intercostal vessels, the internal mammary artery, or lung parenchyma. Venous and small-vessel bleeding often stops once the lung re-expands and the visceral pleura is apposed to the parietal pleura, which provides a tamponade effect. Arterial bleeding, particularly from the intercostal or internal mammary arteries, is less likely to stop spontaneously because the arterial pressure exceeds the tamponade pressure of the pleural apposition. Key point! Persistent output above 200 mL/hour for 2–4 hours suggests an arterial source that will not tamponade, and that is the physiologic rationale for proceeding to thoracotomy.

The drainage record in option 1 shows a sustained rate of 210–230 mL/hour for three consecutive hours. This pattern is consistent with an arterial bleed that is not responding to pleural apposition and chest tube drainage alone. The client is losing blood at a rate that will quickly lead to hemodynamic compromise if not surgically controlled.

Clinical application for the nurse monitoring three clients

The nurse assigned to monitor all three injured clients must recognize which drainage pattern requires escalation. The client with record 1 needs immediate notification of the trauma surgeon and preparation for possible thoracotomy, including ensuring blood products are available, monitoring for signs of hypovolemic shock, and documenting the hourly drainage accurately. The clients with records 2, 3, and 4 can continue to be monitored with serial drainage measurements, vital signs, and hemoglobin checks, because their patterns suggest bleeding is slowing.

Accurate hourly documentation of chest tube output is a nursing responsibility that directly informs the surgical decision. Underestimating or overestimating output can delay necessary surgery or lead to an unnecessary thoracotomy. The drainage system should be checked for patency, and the collection chamber should be marked at the start of each hour to obtain a true hourly volume rather than a cumulative estimate.

## 임상 시나리오

Hemothorax Drainage: When to Call for ThoracotomyATLS thresholds for surgical exploration
Surgical exploration is indicated by initial drainage of 1,500 mL or more or by 200 mL/hour or more for 2–4 hours. Persistent high output after initial drainage is the most reliable sign of ongoing hemorrhage.

A single large initial output may reflect evacuation of pre-existing blood rather than active bleeding. Trend hourly outputs after the initial volume to distinguish continued bleeding from tamponaded blood.

CautionDo not wait for hypotension to decide. Ongoing chest tube output above 200 mL/hr for 2–4 hours or initial output near 1,500 mL requires immediate surgical consultation and preparation for thoracotomy.

## 핵심 개념

- **Hemothorax** — Accumulation of blood in the pleural space, often from blunt or penetrating chest trauma
- **Thoracotomy** — Surgical opening of the chest wall to control hemorrhage or repair injury
- **ATLS** — Advanced Trauma Life Support guidelines used for trauma assessment and management
- **Chest tube drainage** — Output measured from a tube placed in the pleural space to evacuate blood or air

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