Traumatic hemothorax

Hemothorax is the accumulation of blood within the pleural cavity, most commonly resulting from intrathoracic vessel injuries caused by blunt or penetrating trauma or thoracic surgery. Spontaneous bleeding (i.e., nontraumatic hemothorax) is rare. Clinical features include respiratory distress, diminished breath sounds, and dullness to percussion over the affected lung field. Diagnosis is typically confirmed with chest x-ray, bedside ultrasound, or CT chest. Management most often involves chest tube insertion, evaluation by a thoracic surgeon, and hospital admission. Massive hemothorax may be present at the onset, or develop progressively, and can cause life-threatening hemorrhagic shock that requires urgent thoracotomy for source control and hemostasis.

See “Nontraumatic hemothorax” for the approach to spontaneous hemothorax.

• Penetrating chest trauma
• Blunt chest trauma
• Iatrogenic (e.g., thoracic surgery)

• Hemorrhagic shock (e.g., hypotension, tachycardia)
• Respiratory distress
• Chest pain
• Diminished or absent breath sounds
• Decreased tactile fremitus
• Dullness on percussion
• Flat neck veins
• Associated conditions
  • Flail chest: paradoxical chest movement, chest wall deformity
  • Pneumothorax: subcutaneous emphysema

• Upright CXR
  • Small hemothorax: unilateral blunting of the costophrenic angle
  • Large hemothorax findings include: ^[1]
    • Complete lung opacification
    • Mediastinal shift
    • Tracheal deviation away from the effusion
• eFAST: hypoechoic or anechoic collection in the costodiaphragmatic recess ^[1]
• CT chest with IV contrast: can detect hemothoraces not detected on CXR and additional injuries

Approach ^[1][2][3]

• Follow the ABCDE approach for trauma.
• Small (< 300 mL) or occult hemothorax : Consider chest tube insertion or conservative management in consultation with a specialist. ^[1][4]
• All patients with moderate or large hemothoraces or those undergoing positive pressure ventilation: Insert chest tube into the 5^thintercostal space at the midaxillary line. ^[2][3][5][6]
• Manage other blunt chest injuries and/or penetrating chest injuries.
• Consult trauma or thoracic surgery for evaluation and hospital admission.

Consider chest tube insertion for all hemothoraces, regardless of size. ^[7]

Massive hemothorax ^[2]

• Etiology: most commonly caused by injury to large intrathoracic vessels ^[1][8]
• Clinical features
  • Hemorrhagic shock (e.g., need for multiple blood transfusions)
  • Chest tube output ≥ 1500 mL immediately upon placement
  • Chest tube output ≥ 200 mL/hour for 2–4 hours
  • Tracheal deviation may be present. ^[9]
• Management: urgent thoracotomy

Retained hemothorax ^[3][7]

• Hemothorax that persists following initial chest tube insertion (e.g., due to loculations)
• Treatment options include video-assisted thoracoscopic surgery (VATS) and intrapleural thrombolysis. ^[3]

• Pleural empyema
• Fibrothorax
• Trapped lung

We list the most important complications. The selection is not exhaustive.