What is the treatment for hemothorax?

Treatment of Hemothorax

For traumatic hemothorax, immediate chest tube thoracostomy (tube thoracostomy) is the definitive first-line treatment, with surgical exploration reserved for massive initial drainage (>1000 mL) or ongoing blood loss (>200 mL/hour for 3+ hours). 1

Emergency Management: Tension Hemothorax

If the patient presents with tension hemothorax (tracheal shift, distended neck veins, shock, pallor, cold extremities):

• Perform immediate needle thoracostomy at the 2nd intercostal space in the midclavicular line using a No. 14 gauge needle (minimum 7-8 cm length for adults) to convert tension hemothorax to simple hemothorax 1, 2
• Delay of even minutes can be fatal 1, 2
• This is a temporizing measure only—definitive chest tube placement must follow immediately 2

Definitive Management: Standard Hemothorax

Initial Treatment Algorithm

Step 1: Chest Tube Placement

• Insert chest tube in the 4th/5th intercostal space in the midaxillary line 1, 2
• Tube size selection: 1, 3
  • Stable patients: 16F to 22F
  • Unstable patients or those requiring mechanical ventilation: 24F to 28F
• Connect to water seal device with or without suction 1, 3
• Apply suction if lung does not re-expand with water seal alone 3

Step 2: Consider Thoracic Irrigation

• Irrigation with 1 L of warmed sterile 0.9% saline at the time of initial tube placement significantly reduces retained hemothorax (secondary intervention rate decreased from 21.8% to 5.6%) 4
• This represents a critical preventive measure that is often overlooked 4

Indications for Immediate Surgical Exploration

Proceed directly to surgery if: 1

• Initial chest tube drainage exceeds 1000 mL, OR
• Ongoing blood loss exceeds 200 mL/hour for 3 or more consecutive hours

These criteria suggest major vessel injury or significant lung laceration requiring operative repair 1. The clinical course after chest tube insertion should determine whether exploration is necessary 5.

Management of Retained Hemothorax

If blood remains in the pleural cavity after initial tube thoracostomy:

• Most hemothoraces resolve with tube thoracostomy alone 6, 5
• For retained hemothorax, intrapleural fibrinolytic therapy is the most promising medical intervention to disrupt clotted blood and allow further drainage 6
• Video-assisted thoracoscopic surgery (VATS) has largely replaced open thoracotomy for retained hemothorax in non-emergent situations, with improved recovery and reduced postoperative pain 6
• Open thoracotomy remains indicated only if all other interventions fail 6

Monitoring and Tube Removal

• Confirm complete resolution with chest radiograph before tube removal 3
• Remove chest tube in a staged manner after confirming air leak has resolved 3
• Provide adequate analgesia (oral and intramuscular) throughout treatment 3

Critical Pitfalls to Avoid

• Inadequate needle length during decompression (must be ≥7-8 cm for adults) can result in failed pleural penetration 1, 2
• Improper chest tube placement or kinking leads to inadequate drainage and persistent hemothorax 1
• Failure to irrigate at initial placement misses an opportunity to prevent retained hemothorax 4
• Delayed recognition of ongoing hemorrhage requiring surgery—monitor drainage volumes closely in the first 3 hours 1

Special Considerations

For combined thoracoabdominal injuries, prioritize thoracic drainage for the hemothorax component first, then determine surgical sequence based on patient stability 1. In severe cases, two surgical teams may operate simultaneously 1.