What is the most appropriate management for a patient with progressive dyspnea, absent breath sounds on one side, hypoxemia, and a history of recent trauma?

Management of Post-Traumatic Hemothorax

Chest tube insertion is the most appropriate management for this patient with progressive dyspnea, absent breath sounds on the right side, hypoxemia, and recent trauma. 1

Clinical Presentation Analysis

This patient presents with a classic constellation of findings indicating a large hemothorax or pneumothorax following blunt chest trauma:

• Progressive dyspnea over 5 days with absent breath sounds on the right side indicates significant pleural space pathology 1
• Recent trauma (2 weeks ago) is the key historical feature linking this presentation to post-traumatic complications 1
• Hypoxemia (SpO2 90%) with tachypnea (RR 24/min) demonstrates respiratory compromise requiring urgent intervention 2, 3
• Anemia (Hb 90 g/L) suggests ongoing or recent bleeding, most consistent with hemothorax 1

Why Chest Tube Insertion is Indicated

The combination of unilateral absent breath sounds, hypoxemia, and recent trauma mandates immediate chest tube placement to drain accumulated blood or air from the pleural space. 1

• The European trauma guidelines recommend chest tube insertion without delay for traumatic hemothorax or pneumothorax causing respiratory compromise 1
• Delayed presentation (5 days of progressive symptoms) suggests a retained hemothorax that requires drainage to prevent complications such as empyema or fibrothorax 1
• The patient's hemodynamic stability (BP 100/70, HR 90) allows for chest tube placement as the definitive intervention rather than requiring emergency thoracotomy 1

Why Other Options Are Inappropriate

Antibiotics (Option A) would only be indicated if there were signs of infection such as fever or elevated WBC, which are absent in this case 1

Anticoagulation (Option B) is contraindicated in the setting of suspected hemothorax with anemia, as it would worsen bleeding 1

Salbutamol nebulizer (Option D) treats bronchospasm but would not address the mechanical problem of pleural space occupation causing the absent breath sounds 1

Management Algorithm

1. Immediate chest tube insertion on the affected (right) side to drain the pleural collection 1
2. Supplemental oxygen via reservoir mask at 15 L/min to maintain SpO2 >94% while preparing for the procedure 2, 3
3. Monitor for re-expansion pulmonary edema after drainage, particularly if the hemothorax has been present for several days 1
4. Blood transfusion consideration given the significant anemia (Hb 90 g/L), especially if ongoing bleeding is demonstrated 1

Critical Pitfalls to Avoid

• Do not delay chest tube insertion while obtaining additional imaging if the clinical diagnosis is clear from physical examination and history 1
• Do not administer high-flow oxygen without addressing the underlying mechanical problem of pleural space occupation 2
• Do not assume pneumothorax can be managed conservatively in the trauma setting, even if the patient appears stable, as delayed hemothorax can lead to serious complications 4
• Ensure adequate pain control before and during chest tube insertion, as inadequate analgesia can worsen respiratory mechanics 1