HEMOTHORAX

CLARISSA TAN
YONATHAN STANLY
Definition
Type of pleural effusion in which blood
accumulates in the pleural cavity.
Causes
Primary (traumatic) →
laceration of the lung, great vessels, an intercostal vessel, or an internal
mammary artery from penetrating or blunt trauma.

Non-traumatic (less common) → iatrogenic, lung sequestration, vascular, neoplasia,

coagulopathies, and infectious processes.
Clinical Findings
Clinical findings of hemothorax are broad and may overlap with pneumothorax; include:
Respiratory distress-tachypnea, decreased or absent breath sounds, dullness to percussion.
Chest wall asymmetry, tracheal deviation.
Hypoxia, narrow pulse pressure, and hypotension.

Physical findings should prompt the clinician to consider these conditions:

Distended neck veins → pericardial tamponade, tension pneumothorax, cardiogenic failure, air embolism
"Seat belt sign"→ deceleration or vascular injury; chest wall contusion/abrasion
Paradoxical chest wall movement → flail chest
Facial/neck swelling or cyanosis → superior mediastinum injury with occlusion or compression of superior vena
cava (SVC)
Subcutaneous emphysema → torn bronchus or lung parenchyma laceration
Scaphoid abdomen → diaphragmatic injury with herniation of abdominal content into the chest
Excessive abdominal movement with breathing → chest wall injury
 Diagnosis
Imaging
FAST exam --> evaluates pericardium,
perihepatic, perisplenic and pelvic for
pathological air or fluid
eFAST exam --> oblique view (assess
both hemidiaphragm for hemothorax)
and anterior (assess pneumothorax)
Hemothorax appear as anechoic
between diaphragm and parietal
pleura, heterogenous echo (clotted
blood), spine sign
X ray --> initial diagnostic tool

Laboratory
CBC, CRP, troponin, coagulation profile
Diagnosis
Treatment
Primary Initial resuscitation and management → ATLS
protocol:
Two large bore IVs access
Oxygen monitor
12-lead EKG

Secondary:
Obtain a chest x-ray → supine position.
Minimal collection of blood (defined as less than
300 ml) in the pleural cavity generally requires no
treatment; blood usually reabsorbs throughout
the course of several weeks.
French chest tube → evacuates blood, reduces the
risk of a clotted hemothorax.
Monitoring of blood loss.
Treatment
Minimal collection of blood (defined as less than 300 ml) in the pleural cavity generally requires no
treatment → blood usually reabsorbs throughout the course of several weeks → Treated by analgesia as
needed and observed with repeated imaging at 4 to 6 hours and 24 hours.

Considerations operative intervention:

Greater than 1500 mL of blood obtained immediately → →
chest tube indicates a massive hemothorax
→ require operative intervention.
Drainage of > 200 mL/hr for 2 to 4 hours occurs → consider operative exploration.
→
Initial output of < 1500 mL of fluid, but continue to bleed (200 mL/hr for 2 to 4 hours) require
thoracotomy.
Great vessel or chest wall injury
Pericardial tamponade
Massive Hemothorax
Massive hemothorax results from the rapid accumulation of more than 1500 mL of blood or one- third or
more of the patient’s blood volume in the chest cavity.

Commonly caused by penetrating wound that disrupt the systemic or hilar vessel

The neck veins may be flat due to severe hypovolemia, or they may be distended if there is an associated
tension pneumothorax.
Massive Hemothorax
initially managed → restoring blood volume and decompressing the chest cavity.
Large- caliber intravenous lines, infuse crystalloid, and begin transfusion blood as soon as possible.
Blood from the chest tube can be collected in a device suitable for autotransfusion.
A single chest tube (28-32 French) is inserted, usually at the fifth intercostal space, just anterior to the
midaxillary line, and rapid restoration of volume continues as decompression of the chest cavity is
completed.
The immediate return of 1500 mL or more of blood generally indicates the need for urgent
thoracotomy.
Hemopneumothorax

Presence of both blood and air in the pleural cavity and may be caused by blunt or penetrating trauma.

Management:
Needle aspiration as a definitive treatment of a hemopneumothorax is an obsolute intervention.