What is the management and treatment of hemothorax?

Management and Treatment of Hemothorax

For traumatic hemothorax, immediate tube thoracostomy (chest tube placement) is the definitive initial treatment for most patients, with surgical exploration reserved for massive initial drainage (>1000 mL) or ongoing hemorrhage (>200 mL/hour for 3+ hours). 1

Initial Assessment and Recognition

Clinical Presentation

• Suspect hemothorax in patients with thoracic trauma presenting with chest pain, shortness of breath, signs of shock, and attenuated breath sounds on the affected side 1
• Physical examination reveals decreased or absent breath sounds and dullness to percussion on the affected side 2
• Bedside ultrasound (eFAST protocol) has become a critical diagnostic tool in emergency settings and is now standard in most Level 1 trauma centers 2, 3

Tension Hemothorax Recognition

• Immediate life-threatening emergency characterized by tracheal shift, congested neck veins, shock, pallor, and cold extremities 1, 4
• Delay in treatment can cause death within minutes 1, 4

Management Algorithm

Step 1: Emergency Decompression (Tension Hemothorax Only)

• Perform immediate needle thoracostomy at the 2nd intercostal space in the midclavicular line using a No. 14 puncture needle (minimum 7-8 cm length for adults) to convert tension hemothorax to simple hemothorax 1, 4
• Common pitfall: Inadequate needle length (<7-8 cm) leads to ineffective pleural penetration and treatment failure 4
• Follow immediately with definitive tube thoracostomy 4

Step 2: Definitive Drainage with Tube Thoracostomy

• Insert chest tube in the 4th/5th intercostal space in the midaxillary line for closed thoracic drainage 1, 4
• Chest tube sizing:
  • Stable patients: 16F to 22F 1, 2
  • Unstable patients or those requiring mechanical ventilation: 24F to 28F 1, 2
• Connect to water seal device with or without suction 1, 2
• Apply suction if lung does not re-expand with water seal alone 2
• This approach successfully manages most hemothoraces without surgery 3, 5, 6

Step 3: Determine Need for Surgical Intervention

Immediate surgical exploration is indicated for: 1

• Initial drainage volume exceeding 1000 mL, OR
• Ongoing blood loss exceeding 200 mL/hour for 3+ hours

These criteria suggest major vessel injury or significant lung laceration requiring operative repair 1, 5

Step 4: Management of Retained Hemothorax

Retained hemothorax occurs when residual blood remains after initial tube thoracostomy and carries significant risks for empyema and fibrothorax 3

Treatment options in order of invasiveness:

• Intrapleural fibrinolytics: Most promising therapy for disrupting retained clot and allowing further drainage, though optimal dosing requires further study 3
• Video-assisted thoracoscopic surgery (VATS): Minimally invasive approach that is accurate, safe, and reliable when performed within 5 days post-injury, with decreasing success rates after this window 3, 5
• Open thoracotomy: Reserved as last resort when all other measures fail 3

Antibiotic Prophylaxis Considerations

• For penetrating thoracic trauma requiring chest tube: Antibiotic prophylaxis is protective against empyema and pneumonia 7
• For blunt thoracic trauma: Evidence shows no protective effect of antibiotics against empyema or pneumonia 7
• Retained hemothorax itself is a risk factor for developing pneumonia and empyema, with post-traumatic empyema rates varying from 2-25% 7

Special Considerations

Combined Thoracoabdominal Injuries

• Prioritize thoracic drainage for the hemothorax component first 1
• Determine surgical sequence based on patient's hemodynamic stability 1
• In severe cases, two surgical teams may operate simultaneously 1

Chest Tube Removal

• Remove in staged manner only after confirming air leak has resolved 2
• Obtain chest radiograph to confirm complete hemothorax resolution before removal 2
• Remove tube while patient holds breath in full inspiration 7

Critical Pitfalls to Avoid

• Inadequate needle length during emergency decompression: Use minimum 7-8 cm needles for adults to ensure proper pleural penetration 4
• Improper chest tube placement or kinking: Leads to inadequate drainage and persistent hemothorax 1
• Delayed intervention for retained hemothorax: Early evacuation of blood is essential to minimize morbidity; observation alone for significant hemothorax increases risk of complications requiring multiple procedures 6
• Missing indications for surgical intervention: Failure to recognize ongoing hemorrhage or massive initial drainage delays life-saving surgery 1

Pain Management

• Provide adequate oral and intramuscular analgesia throughout treatment 2
• Consider premedication with atropine to prevent vasovagal reactions during procedures 7
• Small doses of intravenous midazolam for anxious patients 7