The American Journal of Surgery (2011) 201, 766 –769

Clinical Science

Clinical management of occult hemothorax: a prospective

study of 81 patients
Ismail Mahmood, M.D.a, Husham Abdelrahman, M.D.a, Ammar Al-Hassani, M.D.a,
Syed Nabir, M.D.b, Mark Sebastian, M.D.a, Kimball Maull, M.D.a,*

a
Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Box 3050, Al Rayyan Rd., Doha,
Qatar; bDepartment of Radiology, Hamad General Hospital, Doha, Qatar

KEYWORDS: Abstract
Hemothorax; BACKGROUND: Intrapleural blood detected by computed tomography scan, but not evident on plain
Occult hemothorax; chest radiograph, defines occult hemothorax. This study determined the role for tube thoracostomy.
CT scan; METHODS: Hemothorax was quantified on computed tomography by measuring the deepest lamel-
Tube thoracostomy lar fluid stripe at the most dependent portion. Data were collected prospectively on demographics,
injury mechanism/severity, chest injuries, mechanical ventilation, hospital length of stay, complica-
tions, and outcome. Indications for tube thoracostomy were recorded.
RESULTS: Tube thoracostomy was avoided in 67 patients (83%). Indications for chest tube placement
included progression of hemothorax (8), desaturation (4), and delayed hemothorax (2). Patients with
intrapleural fluid thickness greater than 1.5 cm were 4 times more likely to require tube thoracostomy.
CONCLUSIONS: Occult hemothorax can be managed successfully without tube thoracostomy in
most cases. Mechanical ventilation is not an indication for chest tube placement. Accompanying occult
pneumothorax may be expected in 50% of cases, but did not affect clinical management.
© 2011 Elsevier Inc. All rights reserved.

Bleeding into the pleural space accompanies blunt chest
injury in as many as one third of cases.1,2 Occult hemothorax
is present when the computed tomography (CT) scan of the
chest shows intrapleural blood that is not readily apparent or
quantifiable on a supine chest radiograph. Many patients em-
pirically undergo tube thoracostomy after significant hemotho-
rax is diagnosed by chest or abdominal CT scan. The question
is, what is significant in this context? Heretofore, the size of
occult hemothorax requiring tube thoracostomy drainage has
not been defined. The purpose of this study was to evaluate
Presented as a Featured Poster at the Annual Meeting of the South-
western Surgical Congress, March 21, 2010, Tucson, AZ.
* Corresponding author. Tel.: ⫹974-659-1402; fax: ⫹974-439-4972.
E-mail address: maullki@upmc.edu
Manuscript received March 15, 2010; revised manuscript April 29,
2010
occult hemothorax in patients with blunt trauma and determine
the role of tube thoracostomy in their management.
Methods
For the 12-month period ending in September 2009,
2,852 blunt trauma patients were admitted. All multisystem
injured and those with isolated blunt chest trauma were
studied by supine chest radiographs and chest CT. Patients
with occult hemothorax were entered in the study. CT scans
were performed on Siemens Medical Systems 64-slice scan-
ners (Siemens, Erlangen, Germany). Scans were performed
after the administration of 120 mL of iohexol (Omnipaque,
GE Healthcare, Waukesha, WI) injected at 3 mL/s. Images
through the chest were reconstructed at 1.5-mm, 2.5-mm,

0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2010.04.017
I. Mahmood et al. Clinical management of occult hemothorax
and 5-mm slice thickness. Images were analyzed by a single
expert trauma radiologist. Follow-up erect posterior-ante-
rior chest radiograph was used in all patients except those
on mechanical ventilation (n ⫽ 19) to determine the pro-
gression of hemothorax. Demographic data were collected
including age, sex, Injury Severity Score (ISS), length of
hospital stay, and mechanism of injury. Associated chest
injuries were recorded. Each patient with an occult hemo-
thorax was monitored to determine whether a tube thora-
costomy was used in the clinical management and, if so, for
what indication. Complications, including those related to
chest tube insertion, were identified. The diagnosis of pneu-
monia was based on fever, purulent sputum, infiltrate on
chest radiograph, positive tracheal aspirate cultures, and
leukocytosis. Statistical analysis was performed with chi-
square and Student t tests and significance was attributed to
a P value of less than .05. The study was approved by the
Institutional Review Board of Hamad General Hospital.
Results
During the study period, 81 blunt trauma patients were
admitted to the hospital with occult hemothorax, 77 were
Figure 1 (A) Chest radiograph in patient with occult hemotho-
rax; (B) chest CT showing 12-mm occult hemothorax.
767
Table 1 Associated thoracic injuries in the study group
Injury Number (%)
Pulmonary contusion 45 (60)
Occult pneumothorax 41 (51)
Pneumomediastinum 5 (7)
Sternal fracture 4 (5)
Cardiac injury 1
Aortic injury 1
men and 4 were women (Fig. 1). Motor vehicle crashes,
including pedestrian and motorcycle collisions, and falls
from height accounted for 90% of the injured. The average
age was 38 years. The average ISS was 18 (average chest
Abbreviated Injury Scale (AIS), 2.8). Associated injuries
are listed in Table 1. Note that occult pneumothorax oc-
curred in more than half of the patients. More than half also
had 3 or more ribs fractured (Fig. 2). Twenty-one patients
(18%) had hemothorax thickness of more than 15 mm on
CT scan. Nineteen patients required mechanical ventilation
and 18 required general anesthesia. The average length of
stay was 11.8 days (range, 1–79 d).
Sixty-seven patients were treated successfully without
tube thoracostomy, and 12 of 14 patients underwent chest
tube placement between 24 and 48 hours after admission.
Comparison of those treated with and without intervention
showed no significant difference between the groups with
regard to age, ISS, number of ribs fractured, presence of
pulmonary contusions, pneumothorax, or need for ventila-
tory support. Fourteen of 81 patients had obliteration of the
costophrenic angle on follow-up chest radiograph but were
treated successfully without a chest tube. Patients with an
occult hemothorax more than 1.5 cm in thickness on CT of
the chest were 4 times more likely to require a chest tube
insertion compared with those with a thickness of 1.5 cm or
less (P ⬍ .03).
Figure 2 Distribution of rib fractures in study patients.
768
Of the 14 patients requiring tube thoracostomy, 8 were
placed for progression of hemothorax, including 5 with
obliteration of both the hemidiaphragm and costophrenic
angle. Other reasons for chest tube placement were increas-
ing respiratory distress with oxygen desaturation (4 pa-
tients). There were no complications related to the delay in
chest tube insertion. Two patients presented with delayed
hemothorax after hospital discharge. Both left the hospital
with a clear chest radiograph but returned after 7 days with
radiograph-evident hemothoraces. Chest tubes were placed
in both patients. One patient had early but improper intra-
parenchymal placement of a chest tube that failed to evac-
uate intrapleural blood. Thoracotomy was required for clot
evacuation and repair of a lacerated lung. The patient had an
uneventful recovery. Two deaths occurred in the study
group: 1 from blunt cardiac injury with severe heart failure
caused by rupture of the cordae tendinea and tricuspid
valve, and the second death was caused by severe head
injury. Age, mechanism of injury, ISS, need for mechanical
ventilation, presence of pulmonary contusion, number of rib
fractures, or presence of occult pneumothorax were not
predictive of the need for intervention.
Comments
Posttraumatic hemothorax may result in respiratory distress,
respiratory failure, retained clot, fibrothorax, empyema, and
extended hospitalization.3,4 Many of these complications can
be prevented or alleviated by tube thoracostomy. However,
placement of a thoracostomy tube is not without risk, and
drainage may be incomplete. Iatrogenic injuries and other
complications may occur in 25% of patients.5 Selective place-
ment of thoracostomy tubes for hemothorax after blunt trauma
may help minimize this risk. Occult hemothorax can be de-
tected on the most cephalad cuts of the abdominal CT scan or
on the chest CT scan, although quantification requires the
latter. In the supine position, free pleural fluid collects predom-
inantly in the dependent gutter of the posterior pleural space
and appears as a sickle-shaped lamella on transverse views.
This lamella is readily visible, and the greatest measured thick-
ness of fluid lamella is used to reflect total effusion volume.6
Quantitative evaluation of pleural fluid with upright chest
radiographs and pleural sonography has been described.7,8
Ruskin et al7 quantified decubitus pleural fluid measurements
as “small” (⬍1.5 cm), “moderate” (1.5– 4.5 cm), and “large”
(⬎4.5 cm). Eibenberger et al8 described effusions of less than
.5-cm thickness to have a mean volume of 80 mL fluid, 1.5-cm
effusions to measure 260 mL fluid, 2-cm effusions to equal a
volume of 380 mL fluid, and 2.5-cm effusions showed a mean
volume of 580 mL fluid, when effusions were tapped from the
pleural space. Blackmore et al9 found 200 mL to be the min-
imal detectable volume on the posteroanterior radiograph
when the costophrenic angle was obliterated. With a volume of
500 mL, the fluid meniscus obscured the hemidiaphragm.
These results were consistent with previous cadaver studies by
Collins et al.10
The American Journal of Surgery, Vol 201, No 6, June 2011
The increased use of CT in the evaluation of the blunt
trauma patient has led to the identification of hemothoraces
not seen on the supine chest radiograph in 20% to 30% of
patients.11 The significance of these occult hemothoraces is
not clear. Some studies have hinted that no specific inter-
vention is required and that the presence of an occult he-
mothorax does not affect patient care.11,12 Other studies
have suggested that the routine use of CT may lead to
improved therapy and outcomes.1,13
Two recent studies have addressed the specific man-
agement of occult hemothoraces.2,14 Most recently, Staf-
ford et al,14 in a retrospective study, reported 88 patients
with occult hemothorax and compared those treated with
and without tube thoracostomy. They found a significant
number of co-existing occult pneumothoraces, which ap-
peared to determine the need for chest tube insertion in
their series. In an earlier prospective randomized study of
occult pneumothorax, one of the authors (K.M.) deter-
mined that occult pneumothoraces could be managed
successfully without tube thoracostomy in most cases.15
This observation was confirmed in the current prospec-
tive study, showing that size of the blood collection, not
the presence of occult pneumothorax, determined the
need for tube thoracostomy.
Conclusions
Occult hemothoraces can be managed safely without
tube thoracostomy. Intervention should be restricted to
those patients who have an increase in the size of the
hemothorax on follow-up radiographs or become symptom-
atic under observation. Patients with a hemothorax greater
than 15 mm on CT are more likely to require drainage.
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