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USMLE® Step 2 Question of the Day: Hemothorax

Osmosis Team
Published on Dec 27, 2023. Updated on Jan 10, 2024.

We're back with a USMLE® Step 2 CK Question of the Day! Today's case involves a 33-year-old man with penetrating chest trauma, presenting with absent breath sounds, dullness to percussion, and hypoechoic fluid on sonographic examination. As vital signs fluctuate, with a GCS of 15, elevated pulse, and decreased blood pressure, the question lingers: What is the optimal next step in managing this critical situation?

A 33-year-old man is brought to the emergency department after sustaining penetrating chest trauma. Paramedics report the patient was shot over the right chest wall two times. Upon arrival, the patient has a GCS of 15, is speaking in full sentences, and is experiencing pain in the right side of the chest. Temperature is 37.1 °C (98.9 °F), pulse is 110/min, respiratory rate is 22/min, blood pressure is 91/57 mmHg, and oxygen saturation is 98% on room air. On physical examination, there are absent breath sounds over the right chest with dullness to percussion. A focused sonographic examination (E-FAST) demonstrates hypoechoic fluid in the right chest cavity. Which of the following is the best next step in management?

A. Tube thoracostomy

B. Open thoracotomy

C. Rapid sequence intubation

D. Administration of norepinephrine

E. Placement of central venous catheter

Scroll down for the correct answer!

The correct answer to today's USMLE® Step 2 CK Question is...

A. Tube thoracostomy

Before we get to the Main Explanation, let's see why the answer wasn't B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!

Incorrect answer explanations

Today's incorrect answers are...

B. Open thoracotomy 

Incorrect: An open thoracotomy is often indicated for traumatic cardiac arrest with penetrating chest trauma. This patient has not suffered a cardiac arrest.

C. Rapid sequence intubation

Incorrect: This patient has no respiratory distress and has a Glascow coma scale of 15 indicating that he is likely protecting the airway. Rapid sequence intubation is not indicated and may worsen this patient's hypotension, increasing the risk of traumatic arrest.

D. Administration of norepinephrine

Incorrect: While administration of norepinephrine may be necessary for hypotension refractory to fluids, it is not the best next step in management.

E. Placement of central venous catheter

Incorrect: Placement of a central venous catheter should be considered for this unstable patient with evidence of a hemothorax where vasopressors may be needed. However, it should not delay tube thoracostomy.

Main Explanation


assessment of patient with hemothorax


This patient presents following penetrating chest trauma with several findings consistent with hemothorax including absent breath sounds and dullness to percussion over the right chest and a positive E-FAST sonographic examination. Given this patient’s developing hemodynamic instability, the best next step in management is chest tube placement (tube thoracostomy)

Hemothorax refers to the collection of blood within the chest cavity between the chest wall and the pleural space. This collection can be a result of direct trauma to the chest or can occur spontaneously when patients have pre-existing clotting disorders. It’s important to address the hemothorax in a timely manner to avoid a potentially life-threatening hemorrhage, as well as to avoid the formation of a chronic fibrothorax, which is an organized clot within the chest cavity surrounding and restricting the patient’s lung from expanding. Findings that may suggest a substantial hemothorax include diminished/absent breath sounds, dullness to percussion, hypotension, tachycardia, and decreased tactile fremitus. 

The first step in the management of patients with hemothorax is an ABCDE assessment in order to determine if the patient is stable or unstable. Unstable patients, e.g. those with hemodynamic instability, altered mental status, or tension physiology, require immediate decompression via tube thoracostomy. This should be followed by surgical consultation and administration of blood products.

Major takeaway

Unstable patients with hemothorax require immediate tube thoracostomy followed by blood product administration and surgical consultation. 

References

Mowery, N. T., Gunter, O. L., Collier, B. R., Diaz, J. J., Haut, E., Hildreth, A., Holevar, M., Mayberry, J., & Streib, E. (2011). Practice management guidelines for management of Hemothorax and occult pneumothorax. Journal of Trauma: Injury, Infection & Critical Care, 70(2), 510–518. https://doi.org/10.1097/ta.0b013e31820b5c31

Patel, N. J., Dultz, L., Ladhani, H. A., Cullinane, D. C., Klein, E., McNickle, A. G., Bugaev, N., Fraser, D. R., Kartiko, S., Dodgion, C., Pappas, P. A., Kim, D., Cantrell, S., Como, J. J., & Kasotakis, G. (2021). Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the surgery of trauma. The American Journal of Surgery, 221(5), 873–884. https://doi.org/10.1016/j.amjsurg.2020.11.032

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