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HemothoraxEdit

Hemothorax is the accumulation of blood within the pleural space, the thin cavity between the lung and the chest wall. It is most often the result of chest trauma, but it can arise from non-traumatic processes as well, including anticoagulation, coagulopathy, pleural malignancy, or ruptured intrathoracic vessels. The condition can impair breathing and circulating blood volume, making prompt recognition and appropriate management essential. In medical practice, halting ongoing bleeding, evacuating the blood, and treating accompanying injuries are the core goals of care. See also pleural space, trauma, and pneumothorax for related thoracic disorders.

Hemothorax occurs when blood collects in the potential space around the lungs, typically following injury to the chest wall, lungs, or mediastinal structures. The volume of blood and the rate of bleeding determine clinical severity, with larger or rapidly accumulating bleeds more likely to cause respiratory compromise and shock. Clinicians often assess for concurrent injuries, as may occur with blunt or penetrating trauma, and consider the patient’s anticoagulation status. See discussions of trauma care and coagulopathy for context.

Causes and classification

  • Traumatic hemothorax
    • Blunt chest trauma (for example, motor vehicle collisions or falls) can lacerate intercostal vessels or injure pulmonary parenchyma, leading to bleeding into the pleural space.
    • Penetrating injuries (such as gunshot or stab wounds) can directly disrupt pleural or mediastinal vessels.
    • Iatrogenic causes include procedures like thoracentesis, chest tube insertion, central venous catheter placement, or other intrathoracic surgeries that inadvertently injure vessels.
  • Spontaneous and non-traumatic hemothorax
    • Anticoagulation or coagulopathy increases bleeding risk into the pleural space.
    • Malignancy with pleural involvement or rupture of abnormal vessels can bleed into the chest.
    • Other less common causes include pulmonary embolism with infarction, rupture of a thoracic aneurysm, or vascular malformations.
  • Mixed or evolving etiologies
    • In some patients, an initial small bleed may be followed by clots that complicate evacuation and require escalation of care.

Pathophysiology

Blood collecting in the pleural space reduces effective lung expansion and can compromise gas exchange. A large effusion or rapid accumulation shifts mediastinal structures, decreases venous return to the heart, and can precipitate shock if systemic bleeding is substantial. If bleeding continues despite initial measures, the situation may progress to a clotted hemothorax, in which organized clots hinder drainage and lung re-expansion, increasing the need for operative intervention.

Clinical presentation

  • Shortness of breath, chest pain, and tachycardia are common.
  • On examination, there may be decreased or absent breath sounds on the affected side and dullness to percussion.
  • In more severe cases, signs of hypovolemia or shock may appear, including pale skin, sweating, altered mental status, and low blood pressure.
  • If concurrent pneumothorax is present, additional signs such as hyperresonance or tracheal deviation may occur.

Diagnosis

  • Chest radiography (X-ray) often shows a layering pleural fluid collection and may reveal associated injuries. The classic “meniscus” sign can help distinguish a hemothorax from simple fluid.
  • Bedside ultrasound (e.g., focused assessment with sonography for trauma, or FAST) can rapidly detect pleural effusions and guide immediate management.
  • Computed tomography (CT) of the chest provides detailed information about the source of bleeding, chest wall and lung injuries, and the extent of pleural involvement.
  • Laboratory tests, including a drop in hemoglobin and signs of ongoing blood loss, assist in assessing severity and transfusion needs.

Management

Management starts with rapid assessment and stabilization, following principles similar to those in general trauma care. The emphasis is on stopping bleeding, evacuating blood from the pleural space, and supporting respiratory and circulatory function.

  • Initial stabilization
    • Airway, breathing, and circulation (the ATLS framework) are prioritized.
    • Supplemental oxygen and analgesia aid breathing and comfort.
    • Reversal of anticoagulation when feasible and safe is considered in patients with coagulopathy.
  • Drainage of the pleural space
    • Chest tube thoracostomy (tube thoracostomy) is the primary intervention for most hemothoraces. The chest tube is typically placed in the mid-axillary line at the level of the 4th–6th intercostal space.
    • Drainage helps re-expand the lung and removes blood to reduce the risk of empyema and fibrothorax.
    • Tube size is debated; traditional practice used larger-bore tubes, but many stable patients may be managed with smaller-bore tubes as well. The choice depends on clinical judgment and local protocols.
  • Assessment of ongoing bleeding
    • The rate of drainage and hemodynamic stability guide decisions about further intervention.
    • Indications for escalating care include an initial large drainage (for example, a high-volume initial drainage) or persistent or recurrent bleeding (e.g., ongoing loss at high rates).
  • Surgical and advanced interventions
    • If drainage is insufficient or there is clotted hemothorax, operative management is considered.
    • Video-assisted thoracoscopic surgery (VATS) is often preferred for stable patients with clotted hemothorax or persistent bleeding, as it allows clot removal and decortication with less morbidity than open surgery.
    • Thoracotomy may be required for ongoing hemorrhage, hemodynamic instability, or complex injuries not amenable to minimally invasive approaches.
  • Associated therapies
    • Transfusion planning based on ongoing blood loss and physiologic status (often guided by massive transfusion principles in severely injured patients).
    • Antibiotic prophylaxis is not routine for isolated traumatic hemothorax but may be used in the context of surgical intervention or suspected infection.
    • Management of other thoracic injuries and systemic injuries is critical to overall recovery.

Controversies and practice variations

  • Drainage strategy and chest tube size: While large-bore tubes were historically favored for suspected hemothorax, evidence over time has supported the use of smaller-bore tubes for many stable patients. Decisions often balance expected drainage, patient size, and the risk of tube-related complications.
  • Timing of surgical intervention: The threshold for early operative management versus continued radiographic and clinical observation varies by center and circumstance. Some guidelines favor early intervention in cases with suspected clotted blood or persistent bleeding, while others reserve surgery for failure of drainage or deterioration.
  • Use of thoracoscopic approaches: VATS offers advantages in evacuating clots and reducing complications for suitable patients, but availability of expertise and patient stability influence whether VATS or open thoracotomy is chosen.
  • Spontaneous hemothorax in anticoagulated patients: Management requires careful reversal of anticoagulation and consideration of bleeding risk versus thrombosis risk, particularly in patients with cardiovascular disease or cancer.
  • Antimicrobial strategies: Routine antibiotics are not mandated for all hemothoraces, but guidelines differ when infection risk is elevated, such as after thoracic surgery or in the setting of hemothorax with suspected empyema.

Prognosis and outcomes

The prognosis of a hemothorax depends on the mechanism, the timeliness of drainage, the volume of bleeding, and the presence of associated injuries or comorbidities. Prompt chest tube drainage and appropriate escalation to surgery when indicated generally improve outcomes. Delays in control of bleeding or failure to evacuate clotted blood can lead to complications such as infection (empyema) or restricted lung expansion (fibrothorax).

See also