What is the management of a hemothorax (collection of blood in the thoracic cavity) post puncture (after a needle or other object has penetrated the thorax)?

Management of Hemothorax Post Puncture

For hemothorax following thoracic puncture, tube thoracostomy should be performed with placement of a drainage tube in the fourth/fifth intercostal space in the midaxillary line. 1

Diagnosis of Hemothorax

• Clinical presentation typically includes:

  • Chest pain and shortness of breath (major symptoms)
  • Potential shock in severe cases
  • Attenuated or absent breath sounds on the affected side
  • Percussion dullness on examination 1

• Diagnostic tools:

  • B-mode ultrasound is valuable for initial diagnosis, especially in emergency settings
  • Chest X-ray shows opacification of the affected hemithorax
  • CT scan may be used for precise quantification when available 2

Management Algorithm

1. Initial Assessment

• Evaluate hemodynamic stability (blood pressure, heart rate)
• Assess respiratory status (oxygen saturation, respiratory rate)
• Determine severity based on clinical presentation and imaging

2. Immediate Management

• For hemodynamically unstable patients:

  • Provide immediate resuscitation and oxygen therapy
  • Perform urgent tube thoracostomy 1, 3

• For hemodynamically stable patients:

  • Tube thoracostomy remains the treatment of choice 4
  • Place drainage tube in the fourth/fifth intercostal space in the midaxillary line 1

3. Tube Selection and Placement

• Standard chest tube (16F-22F) is typically appropriate
• Consider pigtail catheter in stable patients with smaller collections 5
• Ensure proper positioning with radiographic confirmation after placement

4. Post-Drainage Management

• Monitor drainage output and vital signs
• Consider irrigation with warm sterile saline to decrease need for secondary interventions 2
• Administer antibiotics prior to tube thoracostomy to reduce infection risk 2

Management of Complications

Retained Hemothorax

• Occurs when blood remains in the pleural space despite tube thoracostomy
• Management options:
  • Video-assisted thoracoscopy (VATS) is recommended over thrombolytic therapy
  • Early VATS (≤4 days) is preferred over delayed intervention 5
  • Fibrinolytic therapy may be considered if VATS is not available 4

Persistent Bleeding

• For patients with ongoing bleeding or hemodynamic instability after initial tube thoracostomy:
  • Consider surgical exploration
  • Evaluate for lacerated internal mammary or intercostal arteries or major lung lacerations 3

Hemothorax with Pneumothorax

• For combined hemopneumothorax:
  • Manage with tube thoracostomy
  • Monitor for tension pneumothorax development
  • Consider additional intervention if pneumothorax persists 1

Monitoring and Follow-up

• Monitor for:

  • Signs of clinical deterioration (increasing dyspnea, tachycardia, hypotension)
  • Adequate drainage through the chest tube
  • Resolution on follow-up imaging

• Chest tube removal criteria:

  • Resolution of hemothorax on imaging
  • Minimal drainage (<100 mL/24 hours)
  • No air leak

Special Considerations

• For occult hemothorax (visible on CT but not on X-ray):

  • Collections <300 mL (approximately 1.5 cm pleural stripe) may be observed in hemodynamically stable patients
  • Approximately 23% of conservatively managed occult hemothoraces will eventually require drainage 6
  • Predictors of failed observation include hemothorax >300 mL and need for mechanical ventilation 6

• Equipment availability:

  • Resuscitation facilities and chest drain equipment should be immediately available when managing patients with hemothorax 1

By following this structured approach to hemothorax management post puncture, clinicians can effectively treat this condition while minimizing complications and optimizing patient outcomes.