What is the management approach for hemithorax?

Management of Hemothorax

Initial Assessment and Stabilization

All patients with hemothorax should undergo immediate chest tube placement (tube thoracostomy) as the primary treatment modality, with tube size determined by clinical stability. 1, 2

Clinical Presentation

• Patients typically present with chest pain, difficulty breathing, and may exhibit signs of shock 1
• Physical examination reveals decreased or absent breath sounds on the affected side with dullness to percussion 1
• Bedside ultrasound (eFAST protocol) should be used for rapid diagnosis in emergency settings, serving as an effective adjunct to chest radiography 1, 2

Chest Tube Selection and Placement

Tube Size Based on Clinical Stability

For unstable patients or those requiring mechanical ventilation:

• Use 24F to 28F chest tubes 3, 1
• These larger tubes are necessary for patients at risk of large pleural air leaks 3

For stable patients:

• Use 16F to 22F chest tubes 3, 1
• Small-bore catheters (≤14F) may be acceptable in select circumstances with small collections and patient preference, though occlusion risk exists 3

Chest Tube Management

The chest tube should be connected to a water seal device with or without suction. 3, 1

• Water seal alone is acceptable for most patients 3
• If lung fails to re-expand with water seal alone, suction must be applied 3, 1
• Heimlich valves may be used but water seal devices are preferred 3

Monitoring and Tube Removal

Staged Removal Protocol

• Remove the chest tube in a staged manner only after confirming the air leak has resolved 1
• Obtain chest radiograph before removal to confirm complete resolution of the hemothorax 1
• Discontinue suction prior to final imaging to ensure no recurrence 4

Management of Retained Hemothorax

If blood remains in the pleural cavity after initial tube thoracostomy, this constitutes a retained hemothorax requiring escalation of therapy. 2

Fibrinolytic Therapy

• Intrapleural fibrinolytics represent the most promising therapy for retained hemothorax 2
• These agents disrupt organized blood clots, allowing for further drainage through the existing chest tube 2

Surgical Intervention

If medical therapy fails, surgical evacuation is indicated:

• Video-assisted thoracoscopic surgery (VATS) is the preferred minimally invasive approach for non-emergent situations 2, 5
• VATS shows considerable improvement in recovery and postoperative pain compared to open thoracotomy 2
• Minithoracotomy with simultaneous VATS (MT + VATS) may be superior for active hemorrhage and massive blood clots, with significantly shorter operative times 5
• Open thoracotomy is reserved for cases where all prior attempts fail 2

Critical Pitfalls and Complications

Risk Factors for Management Failure

Failure of initial hemothorax management requiring secondary intervention occurs in approximately 19% of cases. 6

• Number of rib fractures and pulmonary contusion predict failure in observation cases 6
• Chest injury severity and initial hemothorax volume evacuated predict failure after pleural drainage 6
• Significant variation exists across trauma centers (6-fold difference in failure rates), suggesting institutional practices matter 6

Late Complications of Retained Hemothorax

• Empyema and fibrothorax develop if residual blood is not evacuated 2
• Once late complications occur, morbidity and mortality increase dramatically 2
• Early aggressive management prevents progression to these complications 2

Pain Management

• Adequate oral and intramuscular analgesia should be provided throughout the treatment course 1