HEMOTHORAX 

Hemothorax is the accumulation of blood in the pleural space.
It most commonly results from trauma (blunt or penetrating) but can also occur spontaneously or iatrogenically.

• Minimal hemothorax: <300 mL
• Moderate hemothorax: 300–1000 mL
• Massive hemothorax: >1000–1500 mL of blood initially drained or >200 mL/hr for 3 consecutive hours.

ETIOLOGY

1. Traumatic Causes (Most Common)

• Blunt trauma: rib fractures lacerating intercostal or internal mammary arteries, lung parenchyma.
• Penetrating trauma: injury to chest wall vessels, lung, heart, or great vessels.
• Iatrogenic:
• Central venous catheter insertion
• Thoracentesis
• Pleural biopsy
• Pacemaker lead placement
• Lung/mediastinal surgery.

2. Non-Traumatic (Spontaneous) Causes

• Spontaneous hemothorax:
• Rupture of vascularized adhesions (e.g., from pleuritis or tuberculosis)
• Ruptured vascular malformations or aneurysms
• Neoplasms (mesothelioma, metastatic, angiosarcoma)
• Pulmonary embolism with infarction
• Endometriosis (catamenial hemothorax)
• Coagulopathies or anticoagulant therapy.

PATHOPHYSIOLOGY

• Blood enters pleural space → lung compression → atelectasis → hypoxia.
• Loss of intravascular volume → hypovolemia and shock.
• Clotted hemothorax → acts as a space-occupying lesion and medium for infection → empyema or fibrothorax.

CLINICAL FEATURES

Symptoms

• Dyspnea
• Chest pain (pleuritic)
• Cough
• Signs of shock (tachycardia, hypotension, pallor) if blood loss is significant

Signs

• Inspection: decreased chest movement on affected side
• Palpation: tracheal deviation to opposite side (if large), decreased tactile fremitus
• Percussion: dullness over affected area
• Auscultation: decreased or absent breath sounds
• Signs of hypovolemia: tachycardia, hypotension, cold extremities

DIAGNOSIS

1. Imaging

Chest X-ray

• Homogenous opacity with meniscus sign (blunting of costophrenic angle)
• Mediastinal shift to opposite side in massive hemothorax
• May miss <300 mL of blood in supine films → look for diffuse haziness without clear costophrenic angle.

Ultrasound (E-FAST)

• Most sensitive bedside test for trauma.
• Detects as little as 20–100 mL of pleural fluid.
• Used in emergency to identify hemothorax along with pneumothorax and pericardial effusion.

CT Chest (Contrast-enhanced)

• Gold standard for detecting site and extent of bleeding.
• Detects active extravasation (“contrast blush”).
• Differentiates between clotted and liquid blood.

2. Diagnostic Thoracentesis

• If uncertain diagnosis.
• Fluid appears bloody; diagnostic if:
• Pleural fluid hematocrit ≥50% of peripheral blood hematocrit
• 25–50% suggests hemothorax with dilution.

COMPLICATIONS

• Clotted hemothorax
• Empyema thoracis (infected retained clot)
• Fibrothorax (organization and fibrosis of pleural cavity)
• Persistent pneumothorax (if lung not re-expanding)
• Re-expansion pulmonary edema (after rapid drainage).

Clotted (Retained) Hemothorax – Diagnosis

Retained hemothorax (RH) is blood remaining in the pleural space despite tube thoracostomy.

Common definitions include:

• Residual pleural blood ≥500 mL on CT
• Blood occupying >1/3 of hemithorax on CT
• Residual blood persisting after 72 hours of chest tube drainage

Retained blood eventually organizes into fibrin, loculations, and fibrothorax if not evacuated.

MANAGEMENT

A. Initial Resuscitation (ATLS principles)

• Airway, Breathing, Circulation – address life-threatening issues.
• Oxygen supplementation.
• Large-bore IV access, fluid/blood resuscitation.
• Crossmatch blood and prepare for possible transfusion.
• Monitor vitals, urine output, ABG, Hb/Hct.

B. Definitive Management

1. Tube Thoracostomy (Intercostal Drain)

• Inserted at or above 5th intercostal space, anterior to mid-axillary line within the “triangle of safety”.
• Direct tube posteriorly
• Direct tube inferiorly toward dependent pleural space (posterobasal position)

Older teaching:Large bore tube (36–40 Fr) for every hemothorax.

Current evidence:

• Small-bore drains and pigtails (≈14–24 Fr) are increasingly accepted for stable traumatic hemothorax.
• Large-bore tubes (28–36 Fr) are still preferred for massive hemothorax, clotted blood, or unstable trauma patients. 

Monitor for:

• Initial output:If >1500 mL immediately drained → Massive hemothorax → surgical indication
• Continuous bleeding:>200 mL/hr for 3 consecutive hours → Thoracotomy indicated

2. Surgical Indications (Thoracotomy)

• Massive hemothorax (>1500 mL initial drainage)
• Ongoing bleeding (>200 mL/hr for 3 hrs)
• Failure of lung re-expansion
• Persistent air leak (suggesting bronchovascular injury)
• Clotted/retained hemothorax
• Associated great vessel/cardiac injury

3. Video-Assisted Thoracoscopic Surgery (VATS)

• Used for retained or clotted hemothorax (24–72 hours window optimal).
• Early VATS reduces risk of empyema and fibrothorax.

4. Supportive Measures

• Analgesia (opioid, epidural, intercostal block)
• Antibiotics (controversial—>broad-spectrum, especially with chest tube)

Current EAST guideline (2022) conditionally recommends prophylactic antibiotics at the time of tube thoracostomy for traumatic hemothorax/pneumothorax to reduce empyema, most commonly using cefazolin, usually as a single peri-procedural dose or for ≤24 hours.

The 2024 Global Alliance/WSES recommendations suggest:

• Routine antibiotics are not clearly indicated for uncomplicated blunt chest trauma undergoing chest tube placement
• Antibiotics are more strongly supported for:
• Penetrating thoracic trauma
• Delayed drainage of retained hemothorax
• Thoracic surgery/thoracoscopy cases 

Thus current practice differs slightly between trauma systems.

• Chest physiotherapy for lung expansion
• Serial CXR/Ultrasound to monitor resolution

• No. Current trauma, critical care, and thoracic surgery guidelines do not recommend routine corticosteroids for either hemothorax or pulmonary contusion.
• Budesonide and salbutamol nebulization has no established role in treating pulmonary contusion/hemothorax  itself and should only be used for another indication (e.g., asthma or COPD)

C. Special Situations

1. Clotted/Retained Hemothorax

• If chest tube fails to drain → use VATS or intrapleural fibrinolytic therapy (streptokinase/urokinase) within 48–72 hrs.

2. Coagulopathy-Associated Hemothorax

• Correct INR/platelets prior to drainage if possible.
• Reversal agents or transfusion as indicated.