What is the recommended management for a patient with a mild haemothorax (collection of blood in the pleural cavity) after a rib fracture?

Management of Mild Haemothorax After Rib Fracture

For mild haemothorax following rib fracture, initial management consists of observation with serial monitoring rather than immediate chest tube drainage, provided the patient is hemodynamically stable without respiratory distress. 1

Initial Assessment and Risk Stratification

Immediate Evaluation

• Obtain a standard PA chest radiograph to confirm haemothorax and assess for associated complications including pneumothorax, pulmonary contusion, or additional injuries 1, 2
• Assess hemodynamic stability: monitor blood pressure, heart rate, shock index, and narrow pulse pressure to evaluate for hypovolemic shock 1
• Measure serial hemoglobin/hematocrit and blood lactate (or base deficit if lactate unavailable) to detect ongoing bleeding and tissue hypoperfusion 1

High-Risk Features Requiring Escalation

• Age ≥65 years with multiple rib fractures significantly increases morbidity and mortality risk and warrants ICU admission 2
• Six or more fractured ribs, bilateral fractures, or first rib fracture are high-risk features requiring intensive monitoring 2, 3
• Patients on anticoagulation require close surveillance until the 4th week post-injury, as delayed haemothorax can occur up to 31 days after initial trauma 4

Conservative Management Protocol

Observation Strategy

• Admit for close observation even with mild haemothorax, as delayed progression can occur, particularly within the first 2 days but potentially up to several weeks post-injury 5, 6, 7
• Serial chest radiographs should be obtained to monitor for progression of haemothorax 5, 7
• Monitor for development of respiratory distress, worsening chest pain, or hemodynamic instability 7

Fluid Resuscitation Approach

• Employ restricted volume replacement strategy with target systolic blood pressure 80-90 mmHg (MAP 50-60 mmHg) until bleeding is controlled, in patients without brain injury 1
• Use 0.9% NaCl or balanced crystalloid solution for initial fluid therapy 1
• Add noradrenaline if restricted volume strategy fails to maintain target arterial pressure 1

Indications for Chest Tube Drainage

Chest tube thoracostomy is indicated when:

• Haemothorax is large or rapidly expanding on serial imaging 8, 7
• Patient develops respiratory distress or hemodynamic instability 7
• Recurrent pleural fluid accumulation despite initial conservative management 8

The case series evidence shows that approximately 30% of traumatic haemothorax can be safely observed without drainage if small and stable 5

Pain Management

Multimodal Analgesia

• Scheduled acetaminophen every 6 hours as first-line therapy (not as-needed dosing) 9
• Add NSAIDs (such as ketorolac) as second-line if pain inadequately controlled, carefully considering contraindications 9
• Reserve opioids exclusively for severe breakthrough pain at lowest effective dose 9

Respiratory Support

• Encourage deep breathing exercises and incentive spirometry to prevent atelectasis 9
• Maintain upright seated position when possible 9
• Avoid complete immobilization which leads to splinting and shallow breathing 9

Critical Pitfalls to Avoid

• Do not discharge patients with subcutaneous emphysema, as this is the only identified risk factor for delayed pneumothorax development 5
• Avoid vigorous activity or chest physical therapy during the first several days after injury, as this may precipitate delayed massive haemothorax from intercostal vessel bleeding 6
• Do not rely on initial negative imaging to exclude delayed complications—patients with rib fractures require several days of hospital observation even without obvious initial intrathoracic injuries 6
• Maintain heightened surveillance in anticoagulated patients for up to 4 weeks post-injury, as delayed haemothorax can occur even with initially normal imaging 4

When to Consider Surgical Intervention

Operative rib fixation should be considered when:

• Recurrent or recalcitrant pleural effusion persists despite multiple thoracostomies and drainage attempts 8
• Significantly displaced fractures cause ongoing bleeding or neurovascular compromise 3

However, first rib fractures are generally NOT candidates for surgical stabilization unless causing vascular or nerve damage, as surgical exposure is technically difficult and risky 3

Follow-up and Recovery

• Schedule follow-up within 1-2 weeks of injury 9
• Rib fractures typically heal within 6-8 weeks, with significant pain improvement within 4 weeks with appropriate management 9
• Implement early mechanical thromboprophylaxis with intermittent pneumatic compression while immobile, transitioning to combined pharmacological and mechanical prophylaxis within 24 hours after bleeding control 1