What is the treatment for hemothorax?

Treatment of Hemothorax

For hemothorax, immediate chest tube thoracostomy (tube size 16F-28F depending on stability) is the definitive treatment, with surgical exploration reserved for initial drainage >1000 mL or ongoing blood loss >200 mL/hour for 3+ hours. 1

Immediate Management Based on Clinical Presentation

Tension Hemothorax (Life-Threatening Emergency)

If the patient presents with tracheal shift, congested neck veins, shock, pallor, and cold extremities, this represents tension hemothorax requiring immediate action 2:

• 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, 2
• Delay in needle decompression can cause death within minutes 1, 2
• Follow immediately with definitive chest tube placement 2

Critical pitfall: Inadequate needle length (<7-8 cm) leads to ineffective pleural penetration and failed decompression 2

Simple Hemothorax (Stable Patient)

For hemothorax without tension physiology 1, 3:

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

Indications for Immediate Surgical Exploration

Proceed directly to surgery if 1:

• Initial chest tube drainage exceeds 1000 mL (suggests major vessel injury or significant lung laceration)
• Ongoing blood loss exceeds 200 mL/hour for 3 or more consecutive hours
• Combined thoracoabdominal injuries may require simultaneous surgical teams 1

Management of Retained Hemothorax

If blood remains in the pleural cavity after initial tube thoracostomy 4, 5:

• Early video-assisted thoracoscopic surgery (VATS) within ≤4 days is recommended over late VATS (>4 days) 5
• VATS is conditionally recommended over thrombolytic therapy as first-line treatment for retained hemothorax 5
• Fibrinolytic therapy may be considered but requires further research to define optimal dosing 4
• Retained hemothorax carries significant risk for empyema and fibrothorax if not addressed early 4

Critical pitfall: Improper chest tube placement or kinking leads to inadequate drainage and persistent hemothorax 1

Special Considerations

Aortic Injury

In high-energy trauma mechanisms where aortic rupture is suspected, perform CT angiography before chest tube insertion 6. Draining a hemothorax from aortic injury without bleeding control can cause massive hemorrhage and death 6.

Pain Management

Provide adequate oral and intramuscular analgesia throughout treatment 3

Tube Removal

• Confirm complete resolution of hemothorax on chest radiograph before removal 3
• Remove chest tube in staged manner after air leak has resolved 3

Outcome Expectations

Most hemothorax cases (majority) resolve with tube thoracostomy alone without requiring surgical intervention 1, 4. However, once late complications develop (empyema, fibrothorax), morbidity and mortality increase dramatically 4.