What is the management of hemothorax (accumulation of blood in the thoracic cavity) due to rib fractures?

From the Guidelines

The management of hemothorax due to rib fractures primarily involves chest tube placement for drainage, with tube size typically 28-36 French to effectively evacuate blood, and surgical stabilization of rib fractures (SSRF) should be considered in appropriate cases to improve outcomes. Initial treatment begins with stabilization following ATLS protocols, including airway management, oxygen supplementation, and IV access. For small hemothoraces (<300 mL) with stable patients, observation may be appropriate, but most cases require tube thoracostomy placed in the 4th-5th intercostal space, mid-axillary line. The chest tube should be connected to underwater seal drainage with suction at -20 cm H2O. Ongoing monitoring of drainage volume is essential; output >1500 mL immediately or >200 mL/hour for 2-4 hours typically indicates need for surgical intervention.

Pain control is crucial using multimodal analgesia including NSAIDs, acetaminophen, and opioids as needed, with regional nerve blocks (intercostal, paravertebral, or epidural) providing excellent relief, as supported by the study by De Simone et al. 1. According to the study by Zhang et al. 1, surgical fixation can improve pain score and fracture healing time in elderly patients with simple rib fractures. However, the decision to perform SSRF should be made on a case-by-case basis, considering the patient's overall condition, age, and presence of other injuries, as suggested by the study by Hoepelman et al. 1.

Surgical options include VATS or thoracotomy for retained hemothorax, ongoing bleeding, or if >1500 mL is evacuated initially. Antibiotics are not routinely needed unless infection develops. Respiratory therapy with incentive spirometry helps prevent atelectasis and pneumonia. Follow-up imaging is necessary to ensure complete evacuation and lung re-expansion, with chest tube removal generally appropriate when drainage is <100 mL/24 hours and no air leak is present. The WSES and CWIS position paper on SSRF 1 provides guidance on the indications and contraindications of SSRF, and highlights the importance of a multidisciplinary approach to the management of patients with rib fractures.

Some key points to consider in the management of hemothorax due to rib fractures include:

• The use of multimodal analgesia to control pain
• The importance of early surgical intervention in appropriate cases
• The need for close monitoring of drainage volume and patient condition
• The use of respiratory therapy to prevent complications
• The consideration of SSRF in patients with flail chest, severe pain, and chest wall deformity, as suggested by the study by Sawyer et al. 1.

From the Research

Management of Hemothorax due to Rib Fractures

• The management of hemothorax due to rib fractures involves several approaches, including tube thoracostomy, pigtail catheter placement, thrombolytic therapy, and video-assisted thoracoscopic surgery (VATS) 2.
• For hemodynamically stable patients, pigtail catheters are conditionally recommended for the management of traumatic hemothorax 2.
• In patients with retained hemothorax, VATS is conditionally recommended over thrombolytic therapy, and early VATS (≤4 days) is recommended over late VATS (>4 days) 2.
• The risk factors for delayed hemothorax in patients with rib fractures include the number of total, lateral, and displaced rib fractures, lung contusions, initial minimal hemothorax, and pneumothorax 3.
• Age, mechanical ventilator use, initial hemo- or pneumothorax, and displaced rib fractures are independently associated with delayed hemothorax 3.
• Chest physiotherapy and analgesic therapy may increase the incidence of late hemothorax in patients with three or more isolated rib fractures 4.
• Minimal hemothoraces (<300 ml) may spontaneously regress, and no additional surgical treatment is required if proper follow-up procedures are performed 4.
• The decision to perform surgical intervention for initial hemothorax is well defined, but the best approach for managing retained hemothorax remains controversial 5.
• Clinical suspicion of hemo/pneumothorax requires drainage of the chest, and stable chest trauma with hemo/pneumothorax can be managed with drainage and observation 6.