HEMOTHORAX 

Definition

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).


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)

  • Mainstay of treatment.
  • Inserted in 5th intercostal space, anterior to mid-axillary line.
  • Connect to underwater seal or suction.
  • Drainage allows lung re-expansion and monitors ongoing bleeding.

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 (broad-spectrum, especially with chest tube)
  • Chest physiotherapy for lung expansion
  • Serial CXR/Ultrasound to monitor resolution


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.


PROGNOSIS

  • Depends on cause and associated injuries.
  • Mortality high if massive bleeding from great vessels or delayed intervention.
  • Prompt drainage and resuscitation improve outcomes.