What is the immediate management of a hemothorax in an adult patient?

Management of Hemothorax

Immediate chest tube drainage with a large-bore thoracostomy tube (24F-28F) is the first-line treatment for hemothorax in adult patients, followed by hospitalization for monitoring and potential surgical intervention if drainage is inadequate. 1, 2

Initial Assessment and Stabilization

Hemodynamic status determines the urgency and aggressiveness of intervention:

• Unstable patients (respiratory rate ≥24 breaths/min, heart rate <60 or >120 bpm, O2 saturation ≤90%, abnormal blood pressure) require immediate large-bore chest tube placement (24F-28F) 3, 1
• Stable patients with significant hemothorax should still undergo tube thoracostomy as the primary intervention 1, 2
• Point-of-care ultrasound (eFAST protocol) has become standard for rapid diagnosis in trauma centers, supplementing or replacing initial chest X-ray 1

Chest Tube Management

Tube size and drainage system setup:

• Large-bore tubes (24F-28F) are preferred for hemothorax to prevent clotting and ensure adequate drainage of blood 3, 1
• Smaller tubes (16F-22F) may be insufficient due to the viscosity of blood and risk of tube occlusion 3
• Connect the chest tube to a water seal device with or without suction 3
• Never clamp a chest tube in the setting of hemothorax, as this can lead to tension physiology 4

Indications for Surgical Intervention

Clear criteria exist for escalating to operative management:

Immediate Thoracotomy Indications:

• Initial drainage >1500 mL of blood 5, 1
• Ongoing bleeding >200 mL/hour for 2-4 hours 5, 1
• Hemodynamic instability despite resuscitation 1

Early VATS Indications (≤4 days):

• Retained hemothorax (residual blood after tube thoracostomy) should be treated with early VATS rather than delayed intervention 2
• Failure of lung re-expansion within 48 hours despite adequate drainage 3
• The Eastern Association for the Surgery of Trauma recommends early VATS (≤4 days) over late VATS (>4 days) to prevent complications like empyema and fibrothorax 2

Management of Retained Hemothorax

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

• VATS evacuation is preferred over thrombolytic therapy as the primary intervention for retained hemothorax 2
• Thrombolytic therapy (fibrinolytics infused into pleural space) may be considered in select patients who cannot undergo surgery, though evidence is limited 1
• Retained hemothorax carries significant risk for empyema and fibrothorax if not addressed early 1, 2

Hospitalization and Monitoring

All patients with hemothorax requiring drainage must be hospitalized:

• Management should occur on specialized respiratory or surgical units with experienced staff 3
• Serial chest radiographs are necessary to assess resolution and lung re-expansion 4
• Monitor for signs of ongoing bleeding, infection, or respiratory compromise 4

Special Considerations

Critical safety points:

• Use full aseptic technique during tube insertion to minimize infection risk (empyema occurs in 1-6% of cases) 4
• Avoid sharp metal trocars during insertion due to increased risk of visceral organ injury 3
• Pigtail catheters may be used in hemodynamically stable patients with small hemothorax, though large-bore tubes remain preferred for most cases 2

Surgical Approach Selection

When surgery is indicated:

• Video-assisted thoracoscopic surgery (VATS) is now the preferred minimally invasive approach over open thoracotomy in non-emergent situations 1, 6, 2
• VATS shows considerable improvement in post-operative recovery and pain compared to thoracotomy 1, 6
• Open thoracotomy remains necessary for massive ongoing bleeding or when VATS fails 1, 6
• Digital subtraction angiography (DSA) for bleeding control should be considered when accessible before proceeding to surgery 6

Common Pitfalls to Avoid

• Delaying surgical consultation in retained hemothorax—early intervention (≤4 days) prevents progression to empyema and fibrothorax 2
• Using inadequate tube size—small-bore catheters may occlude with blood clots 3
• Attempting thrombolytics as first-line for retained hemothorax when VATS is available and patient is a surgical candidate 2
• Premature tube removal—ensure complete drainage and lung re-expansion before removal 7