Traumatic hemothorax

Hemothorax is the accumulation of blood in the pleural cavity, most commonly from intrathoracic vessel injury due to blunt or penetrating trauma or thoracic surgery; spontaneous hemothorax is rare. Clinical features include respiratory distress, diminished breath sounds, and dullness to percussion over the affected lung. Diagnosis is confirmed with chest x-ray, ultrasound (eFAST), or CT chest. Management depends on the size of the hemothorax: Observation may be suitable for small hemothoraces in stable patients, moderate to large hemothoraces require chest tube drainage, and massive hemothorax necessitates urgent thoracotomy for hemorrhage control. Complete drainage is critical to prevent complications such as empyema and retained hemothorax.

See “Nontraumatic hemothorax” for the approach to spontaneous hemothorax.

• Penetrating chest trauma
• Blunt chest trauma
• Iatrogenic (e.g., thoracic surgery)

• Hemorrhagic shock (e.g., hypotension, tachycardia)
• Respiratory distress
• Chest pain
• Diminished or absent breath sounds
• Decreased tactile fremitus
• Dullness on percussion
• Flat neck veins
• Associated conditions
  • Flail chest: paradoxical chest movement, chest wall deformity
  • Pneumothorax: subcutaneous emphysema

• Upright chest x-ray
  • Small hemothorax: unilateral blunting of the costophrenic angle
  • Large hemothorax findings include: ; ^[1]
    • Complete lung opacification
    • Mediastinal shift
    • Tracheal deviation away from the effusion
• eFAST: hypoechoic or anechoic collection in the costodiaphragmatic recess ^[1]
• CT chest with IV contrast: can show hemothoraces not visible on chest x-ray and additional injuries

Approach ^[1][2][3][4]

• Follow the xABCDE approach for trauma. ^[5]
• Manage based on hemothorax size.
  • Small (< 300 mL) or occult: Manage with observation and repeat imaging in 24 hours. ^[3][4]
  • Moderate (300 mL – 500 mL): Typically treated with chest tube placement. ^[5]
  • Large (≥ 500 mL): Place chest tube. ^[3][5]
• Manage other blunt chest injuries and/or penetrating chest injuries.
• Consult trauma or thoracic surgery for evaluation and hospital admission.

Guideline recommendations on chest tube size for traumatic hemothorax vary. Small-bore tubes (14–16 Fr) are considered adequate in stable patients, but large-bore tubes (≥ 24 Fr) are preferred in patients with massive hemothorax, ongoing intrathoracic bleeding, or high clot burden. ^[2][3][5]

Massive hemothorax ^[5]

• Etiology: injury to large intrathoracic vessels ^[1][6]
• Diagnosis: mostly clinical, based on presentation and results of intervention ^[3]
  • Hemorrhagic shock
  • > 1500 mL of blood in the chest cavity on imaging
  • Chest tube output > 1500 mL immediately upon chest tube insertion
  • Chest tube output ≥ 200 mL/hour for at least 3–4 hours ^[7]
  • May produce tension physiology (i.e., obstructive shock) ^[5]
• Management
  • Perform immediate tube thoracostomy.
  • Initiate massive transfusion protocol.
  • Consider urgent thoracotomy. ^[3]

Retained hemothorax ^[2][3]

• Residual blood that persists after chest tube drainage
• Increases the risk for developing complications such as empyema and fibrothorax
• Treatment options include video-assisted thoracoscopic surgery (VATS) and intrapleural thrombolysis. ^[2]
• Antibiotic prophylaxis is indicated when draining retained hemothorax.

• Pleural empyema
• Fibrothorax
• Trapped lung

We list the most important complications. The selection is not exhaustive.