What is the management and treatment for a patient with hemothorax?

Management and Treatment of Hemothorax

For patients with hemothorax, tube thoracostomy is the primary initial intervention, with placement of a drainage tube in the fourth/fifth intercostal space in the midaxillary line to evacuate blood from the pleural cavity and allow lung re-expansion. 1

Diagnosis

• Clinical presentation: Chest pain, shortness of breath, and possible shock
• Physical examination: Attenuated or absent breath sounds on affected side, percussion dullness
• Diagnostic tools:
  • B-mode ultrasound is helpful for diagnosis, especially in emergency settings 1
  • Chest X-ray is traditionally used upon hospital arrival 2
  • Extended Focal Assessment with Sonography in Trauma (eFAST) protocol is increasingly used in Level 1 trauma centers 2

Initial Management Algorithm

1. Assess hemodynamic stability:

   • If unstable (tachycardia, hypotension, shock): Immediate tube thoracostomy and fluid resuscitation 1
   • If stable: Management based on size and symptoms

2. Tube thoracostomy placement:

   • Position: Fourth/fifth intercostal space in the midaxillary line 1
   • Size selection:
     • For massive hemothorax: Larger bore chest tube (24F-28F) 1
     • For smaller hemothorax in stable patients: 16F-22F chest tube 1
     • Pigtail catheters (≤14F) may be considered in hemodynamically stable patients 3

3. Post-tube thoracostomy management:

   • Monitor drainage output
   • Assess for lung re-expansion
   • Provide pain control and supportive care
   • Consider antibiotics if indicated

Management of Retained Hemothorax

If blood remains in the pleural space after initial tube thoracostomy (retained hemothorax):

1. Consider fibrinolytic therapy:

   • Infused into pleural space to disrupt clotted blood and facilitate drainage 2
   • May help avoid surgical intervention

2. Video-Assisted Thoracoscopic Surgery (VATS):

   • Indicated if medical therapy fails
   • Should be performed early (≤4 days) rather than late (>4 days) 3
   • Minimally invasive approach with better post-operative recovery compared to thoracotomy 2

3. Open thoracotomy:

   • Reserved for cases where VATS is unsuccessful or not feasible
   • May be necessary for massive hemothorax or ongoing bleeding requiring direct surgical control 2

Special Considerations

• Massive hemothorax: Requires immediate tube thoracostomy and possible surgical intervention if drainage exceeds 1000-1500 mL initially or continues at >200 mL/hr 1

• Occult hemothorax (detected on CT but not on X-ray):

  • Small occult hemothoraces (<300 mL or <1.5 cm pleural stripe) may be observed without tube thoracostomy in select cases 4
  • Failure rate of conservative management is approximately 23.1% 4
  • Predictors of failed observation: hemothorax >300 mL and need for mechanical ventilation 4

Complications and Follow-up

• Monitor for complications:

  • Empyema
  • Fibrothorax
  • Ongoing bleeding

• Follow-up imaging to ensure complete resolution

• Surgical referral if:

  • Persistent air leak or blood drainage
  • Inadequate lung re-expansion
  • Development of empyema or fibrothorax

Prevention of Late Complications

Early and adequate drainage is essential to prevent long-term complications such as empyema and fibrothorax, which significantly increase morbidity and mortality and often require surgical intervention 2.