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Nursing: When Is Drain Output Too Bloody?

Trauma surgeons frequently place some type of drain in their patients, whether it be a chest tube, a damage control system, or a bulb suction drain near the pancreas. On occasion, nursing may become concerned with the character of the output, wondering if the patient is bleeding significantly. How can you tell if the output is too bloody?

First, most drains are in place to drain serous fluid which may have a little blood in it. Drainage that is mostly bloody is very uncommon from these drains, which are typically placed after orthopedic, spine or abdominal surgery. However, some drains are placed in areas where unexpected bleeding may occur, such as:

  • Damage control drain systems – as patients warm up, arterial sources that were not surgically controlled may open up
  • Pericardial drains – more common in cardiac surgery, not trauma
  • Chest tubes in patients with penetrating trauma

What should you do if you have concerns about your patient’s drain output?

  • Familiarize yourself with what kind of drain it is and what it should be draining
  • Look at the volume of output – it takes 500cc of pure blood to drop the patient’s hemoglobin by about 1 gram. Low outputs are not dangerous, even if it is pure blood.
  • Look at the change in output– if it is increasing significantly or changes color, call the physician to evaluate.
  • Look at the color of the output – most drainage ranges from clear to something like cranberry juice and appears to be partially transparent. Look carefully if it appears to be darker or more opaque, and compare it to the blood that you would see in a blood collection tube. Even the darkest drain output usually looks a little watery compared to whole blood. Bright red output needs to be evaluated by a physician.
  • If in doubt, check the fluid’s hematocrit. Whole blood has a hematocrit of 30% or more. Most bloody-looking drain output maxes out at about 5%. If the value is closer to whole blood, have a physician evaluate the patient.

Cardiac Contusion (for Nurses)

Cardiac contusion is an uncommon condition that is too-commonly worried about. It requires extreme blunt force with a significant head-on component. The most common mechanisms are car crashes (steering wheel) and sports injuries.

A true cardiac contusion is very rare. If a patient did not strike their chest hard enough to cause significant and lasting anterior chest pain, they probably do not have one. If the force was enough to cause a sternal fracture, there is some possibility they may have sustained a cardiac contusion. During ED evaluation, if a patient with a significant mechanism does not exhibit any arrhythmias, they do not have a contusion.

Diagnosis is relatively simple: any trauma patient with a likely mechanism who has chest wall pain and a new arrhythmia or cardiac pump failure has a cardiac contusion. Atrial or ventricular arrhythmias are significant, but a ventricular one is significant because it can degenerate into v-tach or worse.Enzyme measurements do not indicate severity of injury or outcome and should not be obtained.

From a nursing standpoint, you should monitor for and report the following:

  • new arrhythmia, especially a ventricular one. Medications or cardioversion may be ordered to treat.
  • Hypotension, pulmonary congestion, or other signs or heart failure. An echocardiogram or vasoactive medications may be ordered.

Remember, true cardiac contusion is rare! If suspected, telemetry is indicated, along with frequent vital signs. Cardiac enzymes should not be ordered, and any indication of cardiac problems (arrhythmia or failure) should be reported and treated promptly.