Article

The American Surgeon

2021, Vol. 87(7) 1140–1144
Outcomes in Delayed Drainage © The Author(s) 2020
Article reuse guidelines:
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DOI: 10.1177/0003134820956343
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Jessica L. Weaver, MD, PhD1, Elinore J. Kaufman, MD2,

Andrew J. Young, MD2, Jane J. Keating, MD2,
Madhu Subramanian, MD2, Jeremy W. Cannon, MD2,
Adam Shiroff, MD2, and Mark J. Seamon, MD2

Abstract
Background: Prompt drainage of traumatic hemothorax is recommended to prevent empyema and trapped lung. Some
patients do not present the day of their trauma, leading to their delayed treatment. Delayed drainage could be challenging
as clotted blood may not evacuate through a standard chest tube. We hypothesized that such delays would increase the
need for surgery or secondary interventions.
Methods: Our trauma registry was reviewed for patients with a hemothorax admitted to our level 1 trauma center from
1/1/00 to 4/30/19. Patients were included in the delayed group if they received a drainage procedure >24 hours after
injury. These patients were matched 1:1 by chest abbreviated injury score to patients who received drainage <24 hours
from injury.
Results: A total of 19 patients with 22 hemothoraces received delayed drainage. All but 3 patients had a chest tube
placed as initial treatment. Four patients received surgery, including 3 who initially had chest tubes placed. Longer time to
drainage increased the odds of requiring intrathoracic thrombolytics or surgery. In comparison, 2 patients who received
prompt drainage received thrombolytics (P = .11) and none required surgery (P = .02). Patients needed surgery when
initial drainage was on or after post-injury day 5, but pigtail catheter drainage was effective 26 days after injury.
Discussion: Longer times from injury to intervention are associated with increased likelihood of needing surgery for
hemothorax evacuation, but outcomes were not uniform. A larger, multicenter study will be necessary to provide better
characterization of treatment outcomes for these patients.

Keywords
hemothorax, thoracic trauma, delayed hemothorax

Background
Chest wall trauma is present in ≥10% of all admitted
trauma patients1 and is responsible for 20-25% of all
trauma-related mortalities.2 Many surviving patients with
chest wall trauma suffer significant long-term pain and
disability.3 Blunt chest trauma is frequently accompanied
by a hemothorax and/or pneumothorax, which occur in
over 80% of patients with more than 2 rib fractures.4
Simple drainage with a chest tube is effective in up
to 90% of cases of hemothorax.5 Drainage of the hemo-
thorax is encouraged to avoid retained hemothorax, which
has been associated with increased risk of developing
empyema and fibrothorax.6,7 If a tube thoracostomy does
not adequately drain a traumatic hemothorax, some pro-
viders will place a second chest tube or place thrombolytics
through the chest tube to break up the clot. However,
if the first tube fails, it is recommended to proceed with
surgical drainage through a video-assisted thoracoscopic
surgery (VATS) to ensure complete drainage if the patient
is at an acceptable surgical risk.7-10
Operative drainage performed more than 5 days from
time of injury has been associated with increased rates
of conversion to thoracotomy, longer hospital stays, and
higher rates of empyema.7,11 This is thought to be because
1
University of California San Diego Division of Trauma, Surgical Critical
Care, Burn, and Acute Care Surgery, San Diego, CA, USA
2
University of Pennsylvania Division of Traumatology, Surgical Critical
Care, and Emergency Surgery, Philadelphia, PA, USA
Corresponding Author:
Jessica L. Weaver, MD, PhD, University of California San Diego
Division of Trauma, Surgical Critical Care, Burn, and Acute Care
Surgery, 200 W Arbor Drive #8896, San Diego 92103-8896, CA, USA.
Email: jlweaver@ucsd.edu
Weaver et al 1141

the longer wait time allows the retained blood to begin to

organize into a fibrothorax, making it more difficult to
drain.8
It is not known, however, whether these treatment
recommendations apply to a hemothorax which presents
in a delayed fashion. Some patients do not present to the
hospital immediately after their injury, thus delaying their
initial evaluation and treatment. There may be a time point
after which simple tube thoracostomy has a low success
rate, and primary surgical intervention should be con-
sidered. The purpose of this study was to determine the
effects of delayed drainage on the effectiveness of tra-
ditional treatment for hemothorax. We hypothesized that
delaying hemothorax drainage would be associated with
increased need for secondary interventions including
surgery.

Methods
This study was approved by the University of Pennsylvania’s
Institutional Review Board. The institutional trauma
registry was reviewed for patients with a hemothorax
admitted to our level 1 trauma center from 1/1/00 to 4/30/
19. Patients were included in the delayed group if
they presented to the hospital with a hemothorax and
received a drainage procedure on admission, but due to
delayed presentation this drainage was >24 hours after
injury. Patients were excluded if they had a small or no
hemothorax on initial evaluation, and went on to develop
a larger hemothorax in the hospital requiring chest tube
placement, as this likely represented some fresh blood
within the thoracic cavity and drainage at that time would
not be considered “delayed” compared to the development
of the hemothorax.
Charts were reviewed for records of chest tube
placement, type and size of tube used, use of tissue
plasminogen activator (tPA) or collagenase through the
chest tube, thoracic surgery consultation, surgical in-
tervention, and interventional radiology (IR) procedures,
as well as the number of days since injury each of these
took place. A chest tube was defined as a tube of 28F or
larger, whereas a pigtail catheter is a 12-14F tube placed at
the bedside using the Seldinger technique. An IR drain is
placed by an interventional radiologist under imaging
guidance and is typically 8F. Age, sex, hospital length of
stay, intensive care unit (ICU) length of stay, injury se-
verity score (ISS), and use of anticoagulation were also
collected. Subjects were also matched 1:1 by chest ab-
breviated injury score (AIS) to patients with a hemothorax
who received drainage <24 hours after injury. Matches
were identified by reviewing all remaining patients in the
database with chest AIS 3-5 and working from most
recent to most remote (as the most recent charts are more
complete). Individual charts were reviewed to confirm
that the patient received prompt (<24 hours drainage) of
Figure 1. Flowchart showing patient selection with delayed
drainage of hemothorax.
hemothorax, as large number of patients were excluded
due to receiving an immediate thoracotomy.
Data were analyzed using descriptive statistics cal-
culated using Excel (Microsoft, Redmond, Washington).
Comparisons between those with prompt vs. delayed
drainage were calculated using a Student’s T-test or chi-
square with SPSS software (IBM, Chicago, Illinois).
Significance was set at P ≤ .05. The primary outcome was
surgical evaluation for retained hemothorax, while sec-
ondary outcomes included additional procedures such as
IR drains, second chest tubes, or use of thrombolytics
through the chest tube.
Results
A total of 567 patients with a diagnosis of hemothorax
were found. A total of 19 patients with 22 hemothoraces
received drainage of their hemothorax 1 or more days after
injury. A flowchart describing patient selection is shown
in Figure 1. Patients were 84.2% men, and age ranged
from 21 to 87 years with a mean age of 53.5 ± 21.5 years.
Mechanisms of injury were fall (57.9%), motor vehicle
crash (15.8%), motorcycle crash (5.3%), pedestrian vs.
1142 The American Surgeon 87(7)

Figure 2. Number of patients treated, type of procedure required, and number of days post-injury to first drainage procedure.

Table 1. Patient Outcomes in Delayed Drainage Group Compared to 1:1 Matching by Chest AIS With Patients who Received
Prompt Drainage.

Delayed drainage Prompt drainage

(n = 19) (n = 19) P-value

Chest AIS 3.6 ± .8 3.6 ± .8 1.0

Injury severity score 18.4 ± 12.0 25.4 ± 11.8 .08
ICU LOS 6.0 ± 9.2 12.0 ± 16.7 .18
Hospital LOS 13.8 ± 13.2 17.4 ± 16.8 .46
Number of patients requiring additional therapy (tPA, 2nd chest tube, 6 2 .11
and IR drain)
Patients evaluated for/receiving surgery 6 0 .02

Abbreviations: AIS, abbreviated injury score; tPA, tissue plasminogen activator; ICU, intensive care unit; IR, interventional radiology; LOS, length of stay.

automobile (5.3%), and other (15.8%). Mean ISS was
18.4 ± 12 and chest AIS 3.6 ± .8.
All but 3 hemothoraces (86.3%) had a chest tube
placed as initial treatment (Figure 2). Initial chest tube
placement ranged from 1-15 days after injury and the
mean was 6.1 ± 5.2 days. Diagnosis of hemothorax was
made by computerized tomography scan of the chest in 11
patients, while 4 had chest tubes placed after plain X-ray,
and 4 could not be determined from available records.
Four patients (21.1%) received surgery (all VATS), in-
cluding 3 who initially had chest tubes placed, and 2 more
were evaluated for surgery, but the thoracic surgeon felt
they were medically too high-risk for surgery. Two pa-
tients (10.5%) required IR drainage and 6 (31.6%) re-
ceived tPA through the chest tube or drain for retained
hemothorax. Of patients who did not receive chest tube
drainage, 1 received an IR drain, 1 received a pigtail drain,
and 1 went straight to surgery. Of the 6 patients who
received or were evaluated for surgery, 2 were on Cou-
madin and 1 had a baseline international normalized ratio
of 1.5. Of the nonsurgical patients, 1 was taking aspirin
and 1 on aspirin and clopidogrel.
Patients with a prolonged time to initial injury were
associated with increased odds of requiring secondary
intervention or surgery (Table 1). In comparison, 2
patients who received prompt drainage received tPA (P =
.11), and none required surgery (P = .02). Patients re-
quired a secondary intervention after drainage on post-
injury day 4 or later, while patients required surgery after
receiving drainage on post-injury day 5 or later. However,
some patients who received initial drainage long after
injury, including 1 patient at 10 and one at 26 days, re-
sponded to simple chest tube or catheter drainage without
requiring additional interventions.
Discussion
The goal of this study was to determine the best treatment
for a hemothorax when it presents in a delayed fashion.
We hypothesized that the delay in treatment would in-
crease the likelihood of the intrathoracic blood having
already coagulated, reducing the effectiveness of chest
tube placement. If chest tube placement has a low like-
lihood of success, it should be avoided. Like all procedures,
this has a risk of complications including injury to the
chest wall, lung, great vessels, or the heart. There is also
the potential for post-removal pneumothorax and the pain
associated with placement. In fact, in a study by Menger
et al, the complication rate for chest tube placement was
over 20%.12 Therefore, if chest tube placement has a high
Weaver et al
likelihood of failure, it may be preferable to use surgical
drainage as primary therapy for patients who are ac-
ceptable surgical candidates.
Our results do show that chest tube placement alone
generally became less effective with increasing time to
drainage. No patient who had chest tube or catheter
drainage on or before post-injury day 3 required a sec-
ondary intervention, while 10 additional procedures were
necessary for the 13 hemathoraces which received
drainage on or after post-injury day 4. All patients who
needed surgery had initial drainage on or after post-injury
day 5. However, results were not always predictable in
individual patients. While there were patients who re-
quired surgery after drainage on only post-injury day 5,
there was 1 patient treated adequately with chest tube
drainage alone with drainage on post-injury day 10, and
even 1 patient adequately treated with a catheter on post-
injury day 26. This disparity is not explained by patients
being on anticoagulating medication. These findings
suggest that the degree of thoracic blood coagulation over
time seems to vary from person to person. It is possible
that blood in the thoracic cavity does not clot normally,
which would have implications for its use in autotrans-
fusion in massive hemorrhage. It is also possible that the
thoracic blood had already begun to breakdown after
coagulation and be reabsorbed, meaning intervention may
have been of limited benefit to the patient.
Our results do not show any statistically significant
difference in ICU or hospital length of stay (LOS) in those
patients who received delayed drainage compared to
matched control patients who received prompt drainage.
However, the mean length of hospital and ICU length of
stay was numerically higher in the prompt drainage group
than in the delayed drainage group. We had speculated
that patients with delayed drainage may have longer
length of stay, especially if initial chest tube drainage was
ineffective and the decision to try chest tube drainage
delayed the decision to proceed to surgery, but in our small
study, the opposite trend appears to be true. This may be
because these patients also had a higher overall (although
again not statistically significantly higher) ISS. This
increase in ISS, despite a match in chest AIS, suggests
that the patients receiving prompt drainage may have
had other injuries which were the primary determi-
nants of ICU of hospital stay, although this cannot be
determined definitively from the data available. It is
possible that in a larger study these ICU LOS and
hospital LOS would be statistically significant and
correlate with the increased ISS in the prompt
drainage group.
The main limitation of this study is its small sample
size. Poor documentation made it difficult to include
patients transferred from other hospitals, as well as those
admitted before the institution of the electronic medical
record. In addition, finding the matched controls was also
1143
challenging, as the high rate of penetrating trauma in our
patient population leads to many patients who re-
ceived an immediate emergency department (re-
suscitative) or operative thoracotomy, as well as many
who were dead on arrival, and thus, could not be
included in the study.
In addition, this study does not specifically address the
problem of delayed development of hemothorax after
injury. On rare occasions, patients presented to the
emergency department immediately after injury have a
normal chest X-ray, and are sent home, only to return in
a few days with a hemothorax that accumulated in the
intervening time. Similarly, some patients are admitted with
a small hemothorax that grows while they are in the
hospital, necessitating chest tube placement. This study
attempts to differentiate and exclude these patients from
those who are present with a large hemothorax that has
been present for several days, as the hemothoraces with
a delayed presentation would have had more time to or-
ganize and coagulate. However, since these patients do not
present at the time of injury, we cannot confirm how long
the hemothorax has been present.
Conclusions
To our knowledge, this study represents the first data for
evaluating outcomes in delayed drainage of hemothorax.
In this study, we found that effectiveness of chest tube
drainage alone decreases on post-injury day 4, but some
patients can be adequately treated with chest tube or
pigtail catheter drainage ten or even 26 days after injury.
Our data demonstrate that there is currently no clearly
followed treatment algorithm for these patients. Simple
chest tube drainage appears to be a reasonable first step if
no clear surgical indication is found, but early consid-
eration should be given to secondary interventions in
patients receiving initial drainage after post-injury day 3.
The variable response to different drainage techniques
brings into question whether the intrathoracic blood co-
agulates normally, which may be an area for future re-
search. A larger, multicenter study is needed to increase
the sample size and provide more definitive outcome
results for patients presenting with this complex problem.
Author’s Note
All work was performed at the University of Pennsylvania
Division of Traumatology, Surgical Critical Care, and Emer-
gency Surgery.
Presented at the 2020 Academic Surgical Congress in
Orlando, Florida.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with re-
spect to the research, authorship, and/or publication of this article.
1144
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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