What is the management of a patient with haemothorax (blood in the pleural space)?

Management of Haemothorax

The management of haemothorax requires immediate chest tube drainage as the primary intervention, with surgical exploration indicated for massive bleeding or persistent blood loss.

Definition and Diagnosis

Haemothorax is defined as a collection of blood in the pleural cavity, which can result from various causes:

• Traumatic causes: Most common - blunt or penetrating chest trauma 1
• Iatrogenic causes: Complications from procedures such as central venous catheter insertion, lung biopsy, or chest tube placement 2, 3
• Spontaneous causes: Less common - anticoagulant use, neoplasia, vascular abnormalities 4, 5

Diagnostic Approach

• Chest X-ray: Traditional first-line imaging modality
• Ultrasound: Point-of-care ultrasound (eFAST protocol) has high sensitivity and specificity 1
• CT scan: May be required for better characterization in complex cases

Initial Management

1. Resuscitation and stabilization:

   • Oxygen administration
   • IV access and fluid resuscitation
   • Blood product replacement as needed 2

2. Chest tube drainage:

   • Insert a large-bore chest tube (16F-22F) for adequate drainage 2
   • Monitoring of drainage output is essential 1

3. Antibiotics:

   • Prophylactic antibiotics for 24 hours in trauma patients 4

Decision Algorithm Based on Clinical Presentation

Massive Haemothorax

• Definition: >1,500 ml of blood accumulated or >200 ml/hour drainage 4
• Management:
  • Immediate surgical exploration via VATS or thoracotomy
  • Blood product resuscitation
  • Identification and control of bleeding source 2, 4

Moderate Haemothorax

• Management:
  • Chest tube drainage
  • Close monitoring of output
  • If drainage is inadequate with retained blood:
    • Consider intrapleural fibrinolytic therapy to break down clots 1, 4
    • If unsuccessful, proceed to VATS 4

Small/Minimal Haemothorax

• Management:
  • Observation may be appropriate if minimal and patient is stable
  • Monitor for expansion or clinical deterioration
  • Treat underlying cause

Specific Considerations

Arterial Bleeding

For haemothorax caused by arterial injury (e.g., intercostal, internal mammary, or subclavian arteries):

• Management:
  • Supportive care and resuscitation
  • Urgent contact with clinical team
  • May require assistance from thoracic surgeons or interventional radiologists 2
  • Do not remove catheters that may be occluding vessel damage until surgical support is available 2

Retained Haemothorax

If blood remains in the pleural space despite tube thoracostomy:

• Complications:

  • Empyema
  • Fibrothorax
  • Increased morbidity and mortality 1

• Management options:

  1. Intrapleural fibrinolytic therapy
  2. VATS for evacuation (preferred over thoracotomy in non-emergent cases)
  3. Open thoracotomy if other methods fail 1, 4

Monitoring and Follow-up

• Monitor vital signs, oxygen saturation, and chest tube output
• Serial hemoglobin measurements to detect ongoing bleeding 2
• Follow-up imaging to ensure complete resolution
• Address underlying cause to prevent recurrence

Special Situations

Iatrogenic Haemothorax

• May occur despite proper technique during procedures like central line placement or chest tube insertion 2, 3
• Requires same management principles as traumatic haemothorax
• May require urgent surgical intervention even with small-bore tube placement 3

Spontaneous Haemothorax

• Investigate underlying cause (coagulopathy, vascular abnormalities, neoplasm)
• Consider early surgical intervention even if initially stable, as delayed re-bleeding can be fatal 5

Complications

• Empyema
• Fibrothorax with lung entrapment
• Respiratory compromise
• Hypovolemic shock
• Death if not promptly and appropriately managed

The management of haemothorax requires prompt recognition, appropriate intervention, and close monitoring to prevent serious complications and ensure optimal outcomes.