A 28-year-old woman is brought to the emergency department 15 minutes after a stab wound to the left lower chest. On arrival, she is alert, BP 98/64 mmHg, HR 118/min, RR 22/min, and pale. Breath sounds are present bilaterally. Two large-bore IVs are in place. A FAST examination shows no pericardial fluid, no free fluid in the abdomen, but a small left-sided pleural effusion. Chest X-ray shows a small left hemothorax. What is the most appropriate next step?

Clinical Context: Penetrating Thoracic Trauma with Hemodynamic Instability

This patient has:

Why Chest Tube + Preparation for Thoracotomy is Correct

The critical distinction here is hemodynamic status. While a small hemothorax in a truly stable patient may be observed, this patient is hemodynamically unstable (hypotension + tachycardia + pallor). Per ATLS 10th Edition, any hemothorax in a hemodynamically unstable patient warrants immediate chest tube insertion regardless of size, for two reasons:

Furthermore, a stab wound to the left lower chest carries a high risk of diaphragmatic injury and ongoing intrathoracic hemorrhage. If chest tube output is ≥1500 mL immediately or ≥200 mL/hour for 2–4 hours, emergency thoracotomy is indicated. Preparing for thoracotomy at the time of chest tube insertion is the correct surgical mindset per ATLS and EAST guidelines.

Management Decision Tree for Hemothorax

Why Other Options Are Wrong

Key Point:

Hemodynamic instability changes the management of even a "small" hemothorax. In an unstable patient with penetrating chest trauma, immediate chest tube insertion and preparation for thoracotomy is the correct next step per ATLS 10th Edition.

Clinical Pearl:

The threshold for emergency thoracotomy after chest tube insertion:

ATLS 10th Edition, Chapter 4 — Thoracic Trauma; EAST Guidelines for Penetrating Thoracic Trauma