YAJEM-57028; No of Pages 3

American Journal of Emergency Medicine xxx (2017) xxx–xxx

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Longest delayed hemothorax reported after blunt chest injury

Darren Yap, Junior Clinical Fellow a,⁎, Miane Ng, Core Surgical Trainee b,
Madhu Chaudhury, Foundation Doctor a, Nik Mbakada, Senior Clinical Fellow a
a
Emergency Department, Royal Blackburn Hospital, Haslingden Rd, Blackburn BB2 3HH, United Kingdom
b
Department of Cardiothoracic Surgery, Royal Victoria Hospital, 274 Grosvenor Rd, Belfast BT12 6BA, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Blunt chest injury is a common presentation to the emergency department. However, a delayed
Received 12 September 2017 hemothorax after blunt trauma is rare; current literature reports a delay of up to 30 days. We present a case of
Received in revised form 8 October 2017 44-day delay in hemothorax which has not been previously reported in current literature.
Accepted 9 October 2017 Case report: A 52-year-old Caucasian male first presented to the emergency department complaining of persis-
Available online xxxx
tent right sided chest pain 2 weeks after having slipped on a wet surface at home. His initial chest X-ray showed
fractures of the right 7th and 8th ribs without a hemothorax or pneumothorax.
Keywords:
Thoracic injuries
He returned 30 days after the initial consultation (44 days post-trauma) having increasing shortness of breath. A
Hemothorax chest X-ray this time revealed a large right hemothorax and 1850 ml of blood drained from his chest.
Emergency service There was a complete resolution of the hemothorax within 48 h and the patient was discharged after a 6-week
Hospital follow-up with the chest physicians.
Rib fractures Discussion: Delayed hemothorax after blunt trauma is a rare clinical occurrence but associated with significant
Chest pain morbidity and mortality. The management of delayed hemothorax includes draining the hemothorax and
controlling the bleeding.
Why should an emergency physician be aware of this?: Emergency physicians should be vigilant and weary that
hemothorax could be a possibility after a chest injury despite a delay in presentation. A knowledge of delayed
hemothorax will prompt physicians in providing important advice, warning signs and information to patients
after a chest injury to avoid a delay in seeking medical attention.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction
Chest injury after either a penetrating or blunt trauma is a common
presentation to the emergency department but an unrecognized com-
plication of traumatic hemothorax is potentially life threatening. Rib
fractures from chest trauma are a common in hemothorax cases. Most
hemothorax are predicted to be diagnosed at latest 4 days post-incident
[1]. A diagnosis of delayed blunt traumatic hemothorax after 44 days is
extremely rare and has not been reported in current literature.
2. Case report
A 52-year-old Caucasian male first presented to the emergency
department complaining of persistent right sided chest pain 2 weeks
after having slipped on a wet surface at home. He landed onto the
edge of a wooden coffee table and sustained a direct blunt thoracic
⁎ Corresponding author at: Department of Otolaryngology, Royal Berkshire Hospital,
Craven Rd, Reading RG1 5AN, United Kingdom.
E-mail addresses: darren.yap@nhs.net (D. Yap), mpchaudhury@doctors.org.uk
(M. Chaudhury), nikmbakada@doctors.org.uk (N. Mbakada).
trauma over the lateral aspect of his right chest. He had been self-
medicating with regular over the counter painkillers with minimal
relief. He denied being breathless or having hemoptysis. The pain was
aggravated by deep breathing, coughing and lying on the affected side.
He had a past medical history of asthma and lifelong tobacco smoker
of 36 pack years. He only drank alcohol in moderation over weekends
and worked as a forklift driver in a warehouse. He did not take any
anti-coagulant or anti-platelets regularly.
On the initial presentation, his observations showed oxygen satura-
tion of 97% on room air with a respiratory rate of 16/min. He was tender
over the right chest wall with good bilateral air entry on auscultation.
There was no bruising or evidence of flail chest.
His initial chest X-ray showed fractures of the right 7th and 8th ribs
without a hemothorax or pneumothorax as shown in Fig. 1. The patient
was discharged with painkillers and chest injury advice leaflet with no
further follow-up planned.
Exactly 30 days after the initial consultation (44 days after the day of
trauma) the patient returned to the emergency department having
trouble sleeping due to increasing shortness of breath. Since his last
visit, the pain has been improving until 2 weeks ago when it suddenly
got worse. His shortness of breath progressively worsen over the

https://doi.org/10.1016/j.ajem.2017.10.025
0735-6757/© 2017 Elsevier Inc. All rights reserved.

Please cite this article as: Yap D, et al, Longest delayed hemothorax reported after blunt chest injury, American Journal of Emergency Medicine
(2017), https://doi.org/10.1016/j.ajem.2017.10.025
2 D. Yap et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
Fig. 1. Chest X-ray on initial presentation (14 days post trauma).
week, initially only on exertion, but at time of presentation, the breath-
lessness had debilitated him to walking less than 10 yards. He also
started feeling generally unwell, having rigors, loss of appetite, nausea,
and vomiting.
On examination, he was alert and orientated, with a low grade fever
of 37.6 °C. He had a pulse rate of 96 beats/min; blood pressure of 132/
69 mm Hg and oxygen saturation were 94% on room air with a respira-
tory rate of 24/min. He had reduced air entry on the right side of his
chest and a chest X-ray revealed a large right pleural effusion as
shown in Fig. 2. A computerised axial tomography (CT scan) of the tho-
rax was performed which reported a large right pleural effusion associ-
ated with underlying consolidation and partial collapse of the middle
and right lower lobe, lateral rib fractures of the right 7th and 8th ribs
as shown in Fig. 3.
Given the history of trauma; we treated this patient as a possibility of
delayed hemothorax. Ultrasound guided chest drain was inserted which
drained 1850 ml of foul smelling blood and samples were sent for cytol-
ogy, biochemistry, microscopy, culture and sensitivity.
Fig. 2. Chest X-ray on second presentation (44 days post trauma).
Please cite this article as: Yap D, et al, Longest delayed hemothorax reported after blunt chest injury, American Journal of Emergency Medicine
(2017), https://doi.org/10.1016/j.ajem.2017.10.025
Fig. 3. CT showing 7th rib fracture with hemothorax.
Blood tests showed; WCC 11.6 × 109/l, Neutrophils 9.8 × 109/l, Hb
133 g/l, C-reactive protein 355 mg/l. Coagulation studies, liver and
renal function tests were all within normal ranges.
He was started on antibiotics (co-amoxiclav 1 g; intravenous; three
times a day) recommended by the hospital pharmacology formulary for
a possible empyema and admitted into hospital for observation. Chest
fluid biochemistry showed pH 7.42, LDH 3675 iu/l, amylase 47 iu/l,
glucose 5.4 mmol/l, protein 48 g/l and albumin 25 g/l. Cytology was
reported as a pauci-cellular sample showing scattered lymphocytes,
some macrophages and a few mesothelial cells. Malignant cells were
not seen in this sample. Microbiology reported no organisms seen and
blood culture revealed no growth after 48 h.
A repeat chest X-ray performed 48 h after the chest drain insertion
showed a complete resolution of the hemothorax. The drain was
removed and the patient's symptoms improved dramatically. He was
discharged home with oral antibiotics (Amoxicillin 500 mg; three
time a day for 7 days) and follow-up appointment with the chest physi-
cians in 6 weeks.
At the follow-up clinic, a repeat CT thorax showed complete resolu-
tion of the effusion and non-union of the 7th and 8th fractured ribs. His
breathing was back to normal with occasional mild pain over the non-
united rib fractures. At that point he was discharged with no further
hospital appointments and advised to follow up with his own family
doctor if he developed any problems.
3. Discussion
Hemothorax is defined as the collection of blood within the pleural
space triggered by either a blunt or penetrating trauma. Delayed
hemothorax following a blunt chest injury is a rare attendance in the
emergency department. It is defined as hemothorax which appears
24 h or later after injury [2]. Ritter et al. modified the definition of de-
layed hemothorax as clinical investigations confirming a hemothorax
on the second investigation and absent on the first with the time gap
between the two investigations being as little as 2 h [3].
The most common cause of delayed hemothorax is motor vehicle ac-
cident and pedestrian accidents (80.9%) [4,5]. To our knowledge, a large
hemothorax diagnosed 44 days post trauma has never been reported
within the literature as shown in Table 1. According to Sharma et al.,
 D. Yap et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx 3

Table 1 which could occur after initial consultation at the emergency department
Case reports on delayed hemothoraces [5-12]. [12]. As an emergency physician, it is important to have a high index of
No. Author Year Age Gender Duration of delay suspicion of delayed hemothorax after a blunt injury as delayed or misdi-
1 Blair et al. 1971 n/a n/a n/a
agnosis can be potentially fatal for the patient. Every patient presented to
2 Symbas 1978 n/a n/a n/a the emergency department with a blunt chest injury should be educated
3 Simon et al. 1998 Case series 12 patients 18 h–6 days and given sufficient information about this pathology. Physicians can
4 Misthos et al. 2004 Case series 52 patients 2–14 days provide a patient information leaflet emphasizing important worrying
5 Masuda et al. 2013 56 Male 30 days
signs and symptoms or offer a follow-up appointment for the patient to
6 Chen et al. 2014 60 Male 6 days
7 Ahn et al. 2016 24 Female 13 days avoid a delay in diagnosis.
8 Yap et al. 2017 52 Male 44 days
Ethics approval

hemothorax injury post chest trauma can present as early as 6 h after
the incident up to and including 30 days after the injury [1]. On their re-
view, the average time between chest injury and delayed presentation
is 4 days. Literatures suggest that delayed hemothorax are found in
patients with blunt trauma between 2.1% and 33% [2,5,7].
One common key clinical finding in all cases was having at least one
rib fracture [5]. It has been reported that 92% of delayed hemothorax has
evidence of either multiple rib fractures or solitary displaced fracture [4,
6]. This finding was similar in our case with right lateral 7th and 8th rib
fracture. A fractured rib from a blunt trauma can also cause sternal
fracture or laceration to the diaphragm; presenting as a mixture of
chest pain and worsening shortness of breath [7].
Chest X-ray is the recommended investigation as it can be easily
conducted and cost-effective [5]. CT scan could provide more detailed
images and underlying structural abnormalities. Chest X-ray and CT
scan are helpful in patients who are hemodynamically stable. Portable
ultrasonography is highly sensitive and specific in identifying fluid accu-
mulation in internal cavities under the hands of qualified practitioners;
and it is advantageous over the other modalities in hemodynamically
unstable patients.
Management of delayed hemothorax is controlling the bleeding and
evacuating the collected blood found within the pleural cavity. Once
hemodynamic stability is established, a tube thoracoscopy is conducted
as it involves minimal invasion. Thoracotomy is more invasive and only
performed when a patient is hemodynamically unstable [8].
Current literature suggests that if a patient does not fulfil the criteria
for in-hospital management after a blunt chest trauma; they should still
be observed in an outpatient setting for a minimum of 14 days post
incident, especially if fracture of the lower ribs are noted [5]. The follow-
up management includes a clinical and radiological check-up in 2 weeks
[5]. This is for any anticipated delayed hemothorax allowing excellent
prognosis if diagnosed promptly.
Finally, whilst coagulation abnormalities and thoracic rib fractures
are not known to have a uniform relationship; it is necessary to restrict
patient's alcohol intake for weeks post blunt injury to reduce the
peripheral vessel dilator effects of alcohol on bleeding.
Clinical presentation of pleuritic chest pain and significant dyspnea
post trauma is virtually a confirmation of the presence of hemothorax.
However in patients who have suspected delayed hemothorax but fail
to exhibit any sign of pleural effusion on chest X-ray or do not improve
after drainage, they should be investigated for a possibility of pulmo-
nary embolism. Both these conditions have similar clinical presentation
[6,9].
4. Why should an emergency physician be aware of this?
Blunt trauma delayed hemothoraces have been associated with sig-
nificant morbidity [6]. Delayed hemothorax is thought to be associated
with chest physiotherapy, violent coughing or change in position;
Not applicable.
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
“All authors wrote, edited, read and approved the final manuscript.”
Acknowledgement
Not applicable.
Funding
No funding obtained from external sources.
Consent
Non-identifiable images.
Formal consents are not required for the use of entirely anonymised
images from which the individual cannot be identified- for example,
X-rays, ultrasound images, pathology slides or laparoscopic images,
provided that these do not contain any identifying marks and are not
accompanied by text that might identify the individual concerned.
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Please cite this article as: Yap D, et al, Longest delayed hemothorax reported after blunt chest injury, American Journal of Emergency Medicine
(2017), https://doi.org/10.1016/j.ajem.2017.10.025