What is the management for a patient with massive haemothorax?

Management of Massive Haemothorax

Immediate tube thoracostomy with a large-bore (28-32 Fr) chest tube is the definitive initial treatment for massive haemothorax, followed by urgent surgical consultation for patients showing signs of ongoing bleeding. 1

Immediate Resuscitation and Stabilization

Airway and Breathing

• Administer high-flow oxygen immediately to all patients with massive haemothorax 2, 1
• Prepare for potential intubation if respiratory distress develops 2

Vascular Access and Initial Assessment

• Establish large-bore IV access (ideally 8-Fr central access); if this fails, consider intra-osseous or surgical venous access 2, 1
• Obtain baseline laboratory studies: FBC, PT, aPTT, Clauss fibrinogen (not derived), and cross-match 2
• If available, perform near-patient testing with TEG or ROTEM to guide coagulation management 2, 3
• Assess physiology rapidly: if the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate at this stage 2

Fluid Resuscitation Strategy

• Resuscitate with warmed blood and blood components, NOT crystalloids alone 2, 1
• Use blood group O initially (fastest availability), followed by group-specific, then cross-matched blood 2
• Maintain a 1:1 ratio of red blood cells to fresh frozen plasma until coagulation results are available 1
• Keep platelet count >75 × 10⁹/L, as levels <50 × 10⁹/L are strongly associated with microvascular bleeding 1
• Target fibrinogen >1.5 g/L 3
• Actively warm the patient and all transfused fluids 2

Definitive Haemothorax Management

Tube Thoracostomy

• Insert a large-bore (28-32 Fr) chest tube for massive haemothorax 4, 5
• Large-bore tubes are superior to small-bore catheters in haemothorax because of blood clots and high pleural fluid volumes 4
• Small-bore (14 Fr) catheters have similar failure rates to large-bore tubes but are inadequate for managing the clot burden in massive haemothorax 6, 4

Tranexamic Acid Administration

• Administer tranexamic acid 1 g IV over 10 minutes, followed by 1 g over 8 hours 1, 3
• This must be given within 3 hours of bleeding onset for maximum mortality benefit 1

Indications for Surgical Intervention

Clinical Predictors of Need for Surgery

The following parameters indicate ongoing surgical bleeding requiring thoracotomy 7:

• High pulse rate (>125 bpm) 7
• Low systolic blood pressure after resuscitation (<106 mmHg) 7
• Metabolic acidosis: pH <7.2, bicarbonate <17.8 mEq/L, base excess <-9.1 7
• Elevated lactate (>5.7 mmol/L) is the strongest predictor of need for surgical intervention 7

Surgical Timing

• Consider surgery early, but it may need to be limited to "damage control" initially 2
• Once bleeding is controlled surgically, abnormal physiology can be corrected 2
• Video-assisted thoracoscopy (VATS) has largely replaced open thoracotomy for non-emergent retained haemothorax, with improved recovery and less post-operative pain 5

Alternative to Surgery

• Radiologically-guided arterial embolization is highly effective and may eliminate the need for surgery in select cases 1

Permissive Hypotension During Active Bleeding

• It is important to restore organ perfusion, but it is NOT necessary to achieve normal blood pressure during active bleeding 2
• Avoid vasopressors during active haemorrhage 2, 1

Post-Control Management

Once Bleeding is Controlled

• Aggressively normalize blood pressure, acid-base status, and temperature 2, 1
• Continue active warming 2
• Anticipate and prevent coagulopathy; if present, treat aggressively 2

Critical Care Admission

• Admit all patients to critical care for monitoring 2, 1
• Monitor coagulation parameters, haemoglobin, blood gases, and wound drains to identify overt or covert bleeding 2, 1

Venous Thromboprophylaxis

• Start standard venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state 2, 1
• Temporary inferior vena cava filtration may be necessary in select cases 2

Management of Retained Haemothorax

If Blood Remains After Tube Thoracostomy

• Retained haemothorax carries significant risk for empyema and fibrothorax 5
• Intrapleural fibrinolytics can be infused to disrupt the haemothorax and allow further drainage 8, 5
• If medical therapy fails, VATS is indicated before progression to late complications 5
• Open thoracotomy is reserved for cases where all prior attempts have failed 5

Common Pitfalls

• Do not use crystalloids alone for resuscitation—this worsens coagulopathy and increases mortality 2, 1
• Do not delay tranexamic acid beyond 3 hours—efficacy for mortality benefit is time-dependent 1
• Do not use small-bore chest tubes for massive haemothorax—they are inadequate for managing clot burden 4
• Do not use derived fibrinogen levels—they are misleading; only Clauss fibrinogen is reliable 2
• Do not assume all patients with massive haemothorax require surgery—in blunt trauma, selective conservative management is possible if lactate is low and haemodynamics stabilize 7