{"id":3581,"date":"2023-12-27T14:52:00","date_gmt":"2023-12-27T14:52:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3581"},"modified":"2025-10-01T11:39:34","modified_gmt":"2025-10-01T19:39:34","slug":"usmle-step-2-question-of-the-day-hemothorax","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Hemothorax"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#A_Tube_thoracostomy\" >A. Tube thoracostomy<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#Incorrect_answer_explanations\" >Incorrect answer explanations<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#B_Open_thoracotomy\" >B.&nbsp;Open thoracotomy&nbsp;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#C_Rapid_sequence_intubation\" >C. Rapid sequence intubation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#D_Administration_of_norepinephrine\" >D. Administration of norepinephrine<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#E_Placement_of_central_venous_catheter\" >E. Placement of central venous catheter<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\/#Major_takeaway\" >Major takeaway<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;<strong><em>Today&#8217;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?<\/em><\/strong><\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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 \u00b0C (98.9 \u00b0F), 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?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Tube thoracostomy<\/strong><strong>B. Open thoracotomy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Rapid sequence intubation<br><\/strong><br><strong>D. Administration of norepinephrine<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Placement of central venous catheter<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down for the correct answer!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"A_Tube_thoracostomy\"><\/span><strong>A. Tube thoracostomy<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_answer_explanations\"><\/span>Incorrect answer explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Today&#8217;s incorrect answers are&#8230;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"B_Open_thoracotomy\"><\/span><strong>B.&nbsp;<\/strong>Open thoracotomy&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>An open thoracotomy is often indicated for traumatic cardiac arrest with penetrating chest trauma. This patient has not suffered a cardiac arrest.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"C_Rapid_sequence_intubation\"><\/span><strong>C. Rapid sequence intubation<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>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&#8217;s hypotension, increasing the risk of traumatic arrest.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"D_Administration_of_norepinephrine\"><\/span><strong>D. Administration of norepinephrine<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>While administration of norepinephrine may be necessary for hypotension refractory to fluids, it is not the best next step in management.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"E_Placement_of_central_venous_catheter\"><\/span><strong>E. Placement of central venous catheter<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>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.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"830\" height=\"373\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/assesment-of-patient-with-hemothorax.png\" alt=\"assessment of patient with hemothorax\" class=\"wp-image-3583\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/assesment-of-patient-with-hemothorax.png 830w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/assesment-of-patient-with-hemothorax.png?resize=300,135 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/assesment-of-patient-with-hemothorax.png?resize=768,345 768w\" sizes=\"auto, (max-width: 830px) 100vw, 830px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents following penetrating chest trauma with several findings consistent with&nbsp;<strong>hemothorax<\/strong>&nbsp;including absent breath sounds and dullness to percussion over the right chest and a positive E-FAST sonographic examination. Given this patient\u2019s developing hemodynamic instability, the best next step in management is&nbsp;<strong>chest tube placement (tube thoracostomy)<\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Hemothorax<\/strong>&nbsp;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\u2019s 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\u2019s lung from expanding. Findings that may suggest a substantial hemothorax include diminished\/absent breath sounds, dullness to percussion, hypotension, tachycardia, and decreased tactile fremitus.&nbsp;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.&nbsp;<strong>Unstable patients<\/strong>, e.g. those with&nbsp;<strong>hemodynamic instability<\/strong>, altered mental status, or tension physiology, require immediate decompression via&nbsp;<strong>tube thoracostomy<\/strong>. This should be&nbsp;<strong>followed by surgical consultation<\/strong>&nbsp;and administration of&nbsp;<strong>blood products<\/strong>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_takeaway\"><\/span><strong>Major takeaway<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Unstable patients with hemothorax require immediate tube thoracostomy followed by blood product administration and surgical consultation.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>References<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Mowery, N. T., Gunter, O. L., Collier, B. R., Diaz, J. J., Haut, E., Hildreth, A., Holevar, M., Mayberry, J., &amp; Streib, E. (2011). Practice management guidelines for management of Hemothorax and occult pneumothorax. Journal of Trauma: Injury, Infection &amp; Critical Care, 70(2), 510\u2013518.&nbsp;<a href=\"https:\/\/doi.org\/10.1097\/ta.0b013e31820b5c31\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/doi.org\/10.1097\/ta.0b013e31820b5c31<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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., &amp; 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\u2013884.&nbsp;<a href=\"https:\/\/doi.org\/10.1016\/j.amjsurg.2020.11.032\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/doi.org\/10.1016\/j.amjsurg.2020.11.032<\/a>\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013<br><em><br><strong>Want more &nbsp;USMLE\u00ae Step 2 CK practice questions?&nbsp;<\/strong><\/em><em><strong>Try Osmosis by Elsevier today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png?w=700\" alt=\"Ace your clerkships with clinical practice videos on Osmosis. Watch now.\" class=\"wp-image-544\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n","protected":false},"excerpt":{"rendered":"<p>We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;Today&#8217;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 [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":3582,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1370,45],"tags":[],"class_list":["post-3581","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-step-2-questions","category-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Hemothorax - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Hemothorax - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;Today&#8217;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 [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2023-12-27T14:52:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-01T19:39:34+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-hemothorax.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1080\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Marina Horiates Kerekes, MD &amp; Team\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-hemothorax\"},\"author\":{\"name\":\"Marina Horiates Kerekes, MD &amp; 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