What is the appropriate management for a patient with a right hemothorax and right flank ecchymosis?

Management of Right Hemothorax with Right Flank Ecchymosis

This patient requires immediate chest tube thoracostomy (tube thoracostomy) with a large-bore chest tube (24-36F), along with urgent CT imaging with IV contrast to identify the bleeding source and assess for associated injuries, given the high-risk presentation of hemothorax with flank ecchymosis suggesting significant trauma. 1

Initial Assessment and Imaging

Point-of-Care Ultrasound (POCUS/eFAST)

• Perform immediate bedside POCUS/eFAST to rapidly detect hemothorax in the pleural cavity, which has high specificity (0.96) though variable sensitivity (0.74) for detecting free fluid 1
• POCUS enables appropriate emergency decisions in 98% of severe blunt trauma cases within 30 minutes of arrival 2
• The presence of flank ecchymosis is a critical sign suggestive of renal or retroperitoneal injury requiring further investigation 1

Computed Tomography with IV Contrast

• CT chest with IV contrast is mandatory to identify the bleeding source and evaluate for concomitant cardiovascular, great vessel, or solid organ injuries 1
• CT identifies retroperitoneal hematoma in 100% of cases and is 100% sensitive for intraabdominal injury when abrasion/ecchymosis is present 1
• Whole-body CT (WBCT) should be performed immediately in this hemodynamically unstable patient with flank ecchymosis, as it markedly reduces time to diagnosis and enables prioritization of bleeding sources 1
• The combination of hemothorax and flank ecchymosis warrants evaluation of the entire abdomen and pelvis to exclude renal injury, which occurs in up to 5% of trauma victims 1

Immediate Management

Tube Thoracostomy

• Insert a large-bore chest tube (24-36F) immediately for hemothorax drainage, as this remains the treatment of choice 3, 4
• Most hemothoraces (>90%) resolve with tube thoracostomy alone 3
• Administer antibiotic prophylaxis for 24 hours following chest tube insertion in trauma patients 4

Indications for Surgical Intervention

Proceed immediately to surgical exploration (VATS or thoracotomy) if:

• Initial drainage exceeds 1,500 mL of blood 4
• Ongoing blood loss exceeds 200 mL per hour 4
• Patient remains hemodynamically unstable despite resuscitation 3, 5

Hemodynamic Monitoring

• Monitor vital signs continuously, as systolic blood pressure <100 mmHg is an independent predictor requiring emergency intervention 1
• Serial hemoglobin/hematocrit measurements are essential, as initial normal values may mask early-phase bleeding 1

Associated Injury Evaluation

Renal Injury Assessment

• Flank ecchymosis is a key sign of potential renal injury requiring CT evaluation with delayed imaging to assess for collecting system extravasation 1
• Non-operative management is appropriate for most blunt renal injuries, but CT findings guide the need for angioembolization or surgical intervention 1

Retroperitoneal Hemorrhage

• CT with contrast must evaluate for retroperitoneal hematoma, which CT identifies with 100% sensitivity 1
• The combination of hemothorax and flank ecchymosis raises concern for diaphragmatic injury with associated intraabdominal bleeding 1

Management of Retained Hemothorax

If blood remains in the pleural cavity after initial tube thoracostomy:

• Consider intrapleural fibrinolytic therapy to break down clots and adhesions 4
• This prevents progression to empyema and fibrothorax, which dramatically increase morbidity and mortality 3
• If fibrinolytics fail, proceed to VATS or thoracotomy to prevent late complications 3, 4

Critical Pitfalls to Avoid

• Do not rely on chest radiograph alone: Most hemothoraces (80%) are detected only on CT, and chest radiography underestimates the volume 6
• Do not delay CT imaging: A median time of 19 minutes from admission to CT is associated with decreased mortality from exsanguination 1
• Do not assume isolated thoracic injury: Only 10% of patients with hemothorax have isolated injury without other thoracic or abdominal pathology 6
• Do not miss occult hemothorax on CT: Hemothorax observed on CT only still requires admission (94% admission rate) and may require chest tube placement (30% rate) 6

Disposition

• Hospital admission is mandatory for hemothorax with flank ecchymosis, given the 94-99% admission rate for traumatic hemothorax and high risk of associated injuries 6
• Patients require close monitoring for complications including infection, respiratory compromise, and ongoing hemorrhage 3, 5