What is the appropriate management for chest pain due to hemithorax?

Management of Chest Pain Due to Hemothorax

Immediate needle thoracostomy at the 2nd intercostal space in the midclavicular line is mandatory for tension hemothorax presenting with tracheal shift, shock, and hemodynamic instability, followed by definitive chest tube drainage in the 4th/5th intercostal space. 1, 2

Initial Assessment and Recognition

Clinical Presentation

• Suspect hemothorax in patients with thoracic trauma presenting with chest pain, dyspnea, attenuated breath sounds on the affected side, and dullness to percussion 1, 3
• Tension hemothorax is characterized by tracheal shift, congested neck veins, shock, pallor, cold extremities, and progressive respiratory distress 1, 2
• Physical examination reveals decreased or absent breath sounds on the affected hemithorax with dullness to percussion 3

Diagnostic Approach

• Bedside ultrasound (eFAST protocol) should be performed for rapid diagnosis in emergency settings 3, 4
• Chest X-ray remains the standard imaging modality upon hospital arrival 4
• CT scan of the chest quantifies hemothorax volume using the Mergo formula; drainage is recommended for volumes exceeding 300 mL 5

Management Algorithm

Step 1: Immediate Life-Saving Intervention for Tension Hemothorax

• Perform immediate needle thoracostomy using a No. 14 puncture needle (minimum 7-8 cm length for adults) at the 2nd intercostal space in the midclavicular line to convert tension hemothorax to simple hemothorax 1, 2
• Delay in decompression can cause death within minutes 1, 2
• This converts the immediately life-threatening tension situation to a manageable simple hemothorax 2

Common Pitfall: Inadequate needle length (less than 7-8 cm) leads to improper pleural penetration and ineffective decompression 2

Step 2: Definitive Drainage

• Insert chest tube in the 4th/5th intercostal space in the midaxillary line for closed thoracic drainage 1, 3, 2
• Chest tube size: 24F to 28F for unstable patients or those requiring mechanical ventilation; 16F to 22F for stable patients 1, 3
• Connect to water seal device with or without suction; apply suction if lung does not re-expand with water seal alone 1, 3
• Irrigation with warm sterile saline upon tube placement decreases the rate of secondary interventions 5
• Administer antibiotics prior to tube thoracostomy 5

Common Pitfall: Improper chest tube placement or kinking leads to inadequate drainage and persistent hemothorax 1

Step 3: Determine Need for Surgical Intervention

Immediate surgical exploration is indicated for:

• Initial drainage volume exceeding 1000 mL 1
• Ongoing blood loss exceeding 200 mL/hour for 3 or more consecutive hours 1
• These findings suggest major vessel injury or significant lung laceration 1

Step 4: Management of Retained Hemothorax

• Most hemothorax cases resolve with tube thoracostomy alone 1, 4
• If residual blood remains after tube thoracostomy (retained hemothorax), fibrinolytics infused into the pleural space may be considered to disrupt clot and allow further drainage 4
• Video-assisted thoracoscopy (VATS) is preferred over open thoracotomy for non-emergent retained hemothorax, showing improved recovery and reduced post-operative pain 4
• Open thoracotomy is reserved as last resort if all prior attempts fail 4, 6

Critical Warning: Retained hemothorax carries significant risk for empyema and fibrothorax, dramatically increasing morbidity and mortality 4

Step 5: Chest Tube Removal

• Remove chest tube in staged manner only after confirming air leak resolution 3
• Obtain chest radiograph before removal to confirm complete hemothorax resolution 3

Supportive Management

Pain Control

• Provide adequate oral and intramuscular analgesia throughout treatment 3

Resuscitation for Unstable Patients

• Secure airway if respiratory distress persists after initial decompression 2
• Administer high-flow oxygen 2
• Establish large-bore IV access and initiate blood transfusion to replace lost volume 2

Special Considerations

Combined Thoracoabdominal Injuries

• Prioritize thoracic drainage for hemothorax component first 1
• Determine surgical sequence based on patient's hemodynamic status 1
• In severe cases, two surgical teams may operate simultaneously 1

Pneumonectomy

• Consider only as absolute last resort in extreme cases; mortality rate exceeds 50% 1