What is the recommended treatment for a chest wall hematoma?

Treatment of Chest Wall Hematoma

The recommended treatment for a chest wall hematoma depends on its severity, with conservative management being appropriate for most cases, while larger or expanding hematomas may require surgical intervention or embolization.

Initial Assessment and Management

• Chest wall hematomas should be considered a medical emergency requiring immediate evaluation, especially if they are large, expanding, or causing respiratory compromise 1
• Initial assessment should include evaluation of vital signs, respiratory status, and hemodynamic stability to determine the severity of the condition 1
• Imaging with chest radiography is usually appropriate as the first diagnostic step to assess the extent of the hematoma and identify any associated injuries such as rib fractures 1
• For more detailed evaluation, CT scan with IV contrast is recommended to identify potential sources of active bleeding and determine the exact location and extent of the hematoma 1

Conservative Management

• For small, stable hematomas without active bleeding, conservative management is appropriate and includes:
  • Rest and activity limitation to prevent further bleeding 2
  • Pain management with appropriate analgesics to improve respiratory mechanics 1
  • Close monitoring for signs of hematoma expansion or respiratory compromise 1
  • If the patient is on anticoagulant or antiplatelet therapy, temporary discontinuation may be necessary after weighing risks and benefits 3

Indications for Intervention

• Surgical exploration is necessary in the following circumstances:
  • Hemodynamic instability 2
  • Large hematomas (>1500 ml of accumulated blood) 2
  • Ongoing blood loss (>200 ml per hour) 2
  • Respiratory compromise due to mass effect 1
  • Infected hematoma 2

Intervention Options

• Tube thoracostomy (chest tube placement) is indicated for draining liquid blood in the pleural space associated with the hematoma 2
• For clotted blood that cannot be evacuated by tube thoracostomy alone, options include:
  • Intrapleural fibrinolytic therapy to break down clots and adhesions 2
  • Video-assisted thoracoscopic surgery (VATS) for evacuation of organized hematomas 2
  • Open thoracotomy for extensive hematomas or when active bleeding requires direct visualization and control 2
• Angiographic embolization is an effective alternative to surgery when a specific bleeding vessel is identified on imaging 4

Special Considerations

• For patients on anticoagulant therapy who develop chest wall hematomas, management should include:

  • Assessment of anticoagulation intensity 5
  • Consideration of reversal agents if bleeding is severe 5
  • Once bleeding is controlled, reassessment of the risk-benefit ratio for restarting anticoagulation 5

• For chronic expanding hematomas (developing over months to years):

  • Complete surgical resection is recommended to prevent further expansion 6
  • Monitoring of hemostatic parameters before and after surgery is important 6

Follow-up Care

• After successful treatment of a chest wall hematoma:
  • Monitor for recurrence of bleeding 6
  • Address underlying causes to prevent recurrence 3
  • For patients requiring long-term anticoagulation, consider alternative anticoagulation strategies or dose adjustments 5

Pitfalls and Caveats

• Delayed presentation of chest wall hematomas can occur weeks after the initial trauma, requiring vigilance in patients with recent chest trauma 4
• Spontaneous chest wall hematomas may be the first presentation of underlying conditions such as coagulopathies or malignancies 7
• Dual antiplatelet therapy significantly increases the risk of spontaneous chest wall hematomas and may require temporary modification of therapy 3