What is the management of hemothorax (accumulation of blood in the thoracic cavity)?

Management of Hemothorax

The management of hemothorax requires immediate tube thoracostomy in the 4th/5th intercostal space for drainage, with surgical intervention indicated for massive bleeding (>1000 mL initial drainage or >200 mL/hour for 3+ hours) or retained hemothorax. 1, 2

Initial Assessment and Diagnosis

• Hemothorax should be suspected in patients with thoracic trauma presenting with chest pain, shortness of breath, signs of shock, and attenuated breath sounds on the affected side 3
• Diagnostic tools include chest X-ray (traditional first-line), point-of-care ultrasound (eFAST protocol), and CT scan for more detailed assessment 1
• In cases of tension hemothorax (presenting with tracheal shift, congested neck veins, shock, pallor, and cold extremities), immediate decompression is required to prevent imminent death 4

Management Algorithm

Step 1: Initial Stabilization

• For tension hemothorax (life-threatening emergency):
  • Perform immediate needle thoracostomy at the 2nd intercostal space in the midclavicular line using a No. 14 puncture needle (8.25 cm in length) to convert to simple hemothorax 4, 5
  • This must be done before any other interventions as delay can cause death within minutes 4

Step 2: Definitive Drainage

• Insert chest tube (tube thoracostomy) in the 4th/5th intercostal space for closed thoracic drainage 3, 1
• Chest tube size recommendations:
  • For unstable patients or those at risk for large air leaks: 24F to 28F chest tube 3
  • For stable patients: 16F to 22F chest tubes 3
• Connect to water seal device with or without suction 3

Step 3: Determine Need for Surgical Intervention

• Immediate surgical exploration is indicated if:
  • Initial drainage volume exceeds 1000 mL 2, 6
  • Ongoing blood loss exceeds 200 mL/hour for 3+ hours 2, 6
  • Patient becomes hemodynamically unstable after initial stabilization 2
• These criteria suggest major vessel injury or significant lung laceration requiring surgical repair 3

Step 4: Management of Retained Hemothorax

• If blood remains in the pleural cavity after tube thoracostomy (retained hemothorax):
  • Consider fibrinolytic therapy through the chest tube to disrupt clots and facilitate drainage 1
  • If fibrinolytics fail, early video-assisted thoracoscopic surgery (VATS) is recommended, ideally within 5 days of the initial event 6
  • Open thoracotomy may be required if VATS is unsuccessful or not feasible 1

Special Considerations

• For severe lung lacerations causing hemothorax:

  • Most can be managed with tube thoracostomy alone 3
  • If drainage is ineffective, surgical intervention may include suturing the laceration, lobectomy, segmentectomy, or pneumonectomy in extreme cases 3
  • Note that pneumonectomy carries >50% mortality and should be considered a last resort 3

• For combined thoracoabdominal injuries:

  • Prioritize thoracic drainage for the hemothorax component 3
  • Surgical sequence (thoracotomy vs. laparotomy) should be determined by the patient's condition 3
  • In severe cases, two surgical teams may operate simultaneously 3

Potential Complications and Pitfalls

• Inadequate needle length during initial decompression can lead to ineffective treatment; ensure needles are at least 7-8 cm long for adults 4, 5
• Improper chest tube placement or kinking can lead to inadequate drainage and persistent hemothorax 3
• Delayed management of retained hemothorax can lead to empyema and fibrothorax, significantly increasing morbidity and mortality 1, 6
• Significant center-to-center variation exists in hemothorax management failure rates, suggesting the importance of standardized protocols 7

Predictors of Management Failure

• For patients initially managed with observation:
  • Number of rib fractures and presence of pulmonary contusion increase risk of management failure 7
• For patients initially managed with tube thoracostomy:
  • Higher chest injury severity and larger initial hemothorax volume predict higher failure rates 7