Trauma
Massive Hemothorax
Background
- Definition
- Collection of > 1.5 L of blood in hemithorax
- Equals about 2/3 of hemi-thoracic volume
- Synopsis
- Continued bleeding
- "Massive hemothorax equivalent"
- > 200-300 cc/hr chest tube drainage for 3-4 hrs
- Treatment (ED management)
- Diagnostic imaging to determine severity
- Resuscitation (ATLS)
- Stabilization
- Prep for surgery as needed
- An immediate threat to life
Pathophysiology
- Mechanism
- Mainly altered cardiac and respiratory functions
- Influenced by amount and rate of blood loss
- Life-threatening by 3 mechanisms
- Acute hypovolemia
- Each hemithorax can hold 40-50% of circulating blood volume
- Blood can accumulate rapidly in pleural space
- Decreases preload
- Compromises LV function and cardiac output
- Hypoxia
- From lung collapse
- V/Q mismatching, alveolar hypoventilation, anatomic shunting
- Pressure of hemothorax
- Compresses vena cava
- Further decreases preload
- Compresses lung parenchyma
- Increases pulmonary vascular resistance
- Large clots in pleural space may release fibrinolysins leading to further bleeding
- Residual hemothorax increases osmotic pressure (protein concentration increases 2/2 RBC lysis)
- Leads to fluid transudation and increases pleural fluid volume
- Late sequelae of unresolved hemothoraces
- Empyema and fibrothoraces
- Etiology/Risk Factors
- Usually from blunt or penetrating trauma resulting in vascular injuries to
- Chest wall and associated structures (extrapleural)
- Intercostal arteries or internal mammary arteries
- Can lead to prolonged bleeding
- Blood vessels
- Aorta or brachiocephalic arteries
- SVC, IVC, brachiocephalic veins
- Pulmonary arteries and veins
- Injury to intercostal artery
- Injury to internal mammary artery
- Post-CPR, consider azygos vein rupture
- Lung (rare)
- Lung parenchyma
- High concentration of lung thromboplastin, low pulmonary arterial pressure + compressing effect of blood in pleural space limit bleeding
- Less common etiologies
- Iatrogenic (e.g., central venous catheter or thoracostomy tube placement)
- Disease complication/spontaneous (e.g., neoplasia, thoracic aortic dissection or aneurysm, AVM, lobar sequestration, coagulopathy, endometriosis)
- Epidemiology
- Incidence/Prevalence
- Hemothorax related to trauma around 300,000 cases/year
- 50% of patients with blunt chest trauma
- Incidence of hemothorax and pneumothorax increases with number of ribs fractured
- 5% of those with spontaneous pneumothorax have hemothorax
- Mortality/Morbidity
- Thoracic injuries responsible for 20-25% of all trauma-related deaths
- 15% of those with chest trauma need thoracotomy for definitive management
- Risk factors for mortality among blunt chest wall trauma patients
- Age > 64 years old
- > 2 rib fractures
- Pre-existing disease, especially cardiopulmonary
- Complications of hemothorax include empyema (5%), fibrothorax (1%)
Diagnostics
- History/Symptoms
- Blunt chest trauma
- High risk penetrating wounds
- Potential damage to great vessels, hilar structures, heart increasing likelihood for thoracotomy
- Anterior: medial to nipple line
- Posterior: medial to scapula
- Chest pain
- Shortness of breath
- If no history of trauma or recent surgery, look for spontaneous causes
- If hemothorax + diaphragmatic injury, consider intra-abdominal injury
- Physical Exam/Signs
- General Appearance/Vitals
- Tachypnea, hypoxia
- Possible chest pain, dyspnea, anxiety
- Signs of shock with loss of > 30% (1.5-2.0 L)
- Bruising, lacerations, other evidence of thoracic trauma
- Neck
- Flat neck veins
- Distended neck veins suggest tension pneumothorax
- Tracheal deviation/mediastinal shift if hemothorax large enough
- Pulmonary/Chest
- Decreased breath sounds on affected side (best upright)
- Dullness to percussion on affected side (best upright)
- Decreased or no chest movement with respiration
- Labs/Tests (see also General trauma labs)
- CBC +Diff
- CMP
- Type & Cross for transfusion
- ABG, pulse oximetry
- If nontraumatic/spontaneous
- Pleural fluid cell count and cytology (> 50% plasma hematocrit) and other labs to elucidate etiology
- Imaging
- DO NOT delay treatment for imaging study
- CXR (primary imaging)
- Appearance depends on patient position and amount of blood in pleural space
- Portable supine
- May show only general haziness or opacification of affected lung field, even with 1 L of blood in hemithorax
- Look for rib fractures, pneumothorax, widening of mediastinum
- May see tracheal deviation as part of tension physiology
- Upright (best for primary imaging) (View image)
- Meniscus sign (fluid blunting costophrenic angle and tracking up the pleural margins)
- Blunting of costophrenic angle may equate to 400-500 mL of blood
- Air-fluid interface seen if hemopneumothorax
- Consider repeating for delayed hemorrhage 3-6 hours post-injury (7-9% penetrating thoracic injuries)
- If patient is intubated and one hemithorax is opaque
- Verify that endotracheal tube is not malpositioned in contralateral mainstem bronchus and in need of repositioning
- Ultrasound (bedside)
- Use as part of FAST and as adjunct with CXR
- Shows fluid between chest wall and lung for hemothorax
- With penetrating trauma, provides timely info on pericardial involvement
- Greater sensitivity and equal specificity than CXR
- CT
- Complementary study to CXR
- Use if CXR ambiguous or initial treatment fails
- Highest sensitivity and specificity for hemothorax
- More sensitive for localization of clots, loculated collections
- Used later to guide further treatment
- Other Tests/Criteria
- Differential Diagnosis
Treatment (View Video)
- Initial/Prep/Goals
- ATLS protocol
- Identify and treat life-threatening injuries, control bleeding, volume resuscitation
- Keep patient upright if possible
- Emergent surgery consult- trauma/general, thoracic
- Medical/Pharmaceutical
- Restore blood volume
- Place 2 large bore (> 16-gauge) IV lines
- Obtain 8 units of whole blood (typed and crossed)
- Push IV crystalloid
- Don't forget pain management
- Consider antibiotics if traumatic hemothorax with chest tube insertion (especially if penetrating wound)
- Surgical/Procedural
- Place arterial line but central line not absolute necessity and shouldn't slow treatment
- Decompress chest cavity
- Immediate tube thoracostomy
- Drainage if coagulopathy not contraindicated
- Stop anticoagulants
- Correct factor deficiencies with blood products if necessary/possible prior to thoracostomy
- Use kit, sterile technique, local anesthetic at insertion site
- Use 32-40F
- Large bore has been standard, but more evidence shows smaller with no outcome difference
- Procedural sedation/analgesia if needed
- Insertion
- Anterior axillary line at 5th intercostal space, directed posteriorly and laterally
- Oblique skin incision 1-2 cm below interspace where tube will be placed
- Insert large clamp through incision into intercostal muscles in next higher intercostal space above rib
- Then insert finger along top of clamp and ensure lung is not adhered to chest wall
- Place until last side hole is 2.5-5 cm inside chest wall
- Can be too anterior and superior with supine trauma patient leading to incomplete drainage
- Attach to water-seal suction with 20-30 cm H20 suction
- Repeat Chest X-ray
- Look for tube placement, completeness of evacuation, other pathology previously obscured by fluid
- Emergent thoracotomy indications
- Massive hemothorax or initial drainage > 1.5 L (or in any 24-hour period) after tube thoracostomy
- Continued blood loss of > 150-200 mL/hr for 2-4 hours or drainage > 1.5 L in any 24-hour period
- Persistent need for transfusion
- Clinical decline/hemodynamic instability (loss of protective vascular tamponade or exsanguinating injury)
- If traumatic arrest in ED, consider thoracotomy in ED
- Ventilatory support
- If impaired ventilation continues despite pain management and evacuated hemothorax and as indicated by primary survey
- Watch for potential increase in bleeding from pulmonary vessels if positive pressure ventilation displaces clots
- Consider autotransfusion
- Collect drainage in an autotransfusion-prepared device during chest tube insertion
- If > 1 L of blood loss and blood is NOT contaminated by enteral pathogens (no intraabdominal injury)
- Complications
- Retained hemothorax (collection > 500 mL by CT or 1/3 hemithorax opacified on CXR)
- 10-20% of traumatic hemothoraces
- Complications of tube thoracostomy
- 25-30% overall complication rate
- Pneumothorax
- Re-expansion pulmonary edema
- Spleen or liver puncture
- Infection
- Improper tube placement
- Prevention
Disposition
- Admission criteria
- All patients for monitoring and thoracostomy tube management
- Consults
- Trauma, general, or cardiothoracic surgery
- Discharge/Follow-up instructions
- Per primary care provider recommendations
Related Topics
References
- Emergency Medicine Journal. BET 4: Does size matter? Chest drains in haemothorax following trauma. Emerg Med J. Nov 2013;30(11):965-967
- Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. J Trauma Acute Care Surg. Feb 2012;72(2):422-427
- Mowery NT, Gunter OL, Collier BR, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. Feb 2011;70(2):510-518
- Brooks A, Davies B, Smethhurst M, Connolly J. Emergency ultrasound in the acute assessment of haemothorax. Emerg Med J. Jan 2004;21(1):44-46
- Butler J, Sammy I, Desmond J. Towards evidence based emergency medicine: best BETs from Manchester Royal Infirmary. Antibiotics in patients with isolated chest trauma requiring chest drains. Emerg Med J. Nov 2002;19(6):553-554
- Miller LA. Chest wall, lung, and pleural space trauma. Radiol Clin North Am. Mar 2006;44(2):213-224
- Salhanick M, Corneille M, Higgins R, et al. Autotransfusion of hemothorax blood in trauma patients: Is it the same as fresh whole blood? Am J Surg. Dec 2011;202(6):817-821
- Gomez LP, Tran VH. Hemothorax. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK538219/. [Accessed December 2021]
- Wang YL, Jones D. Pulmonary Trauma. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th ed., New York, NY:The McGraw-Hill Companies, 2020;Chapter 261
Contributor(s)
- Ringelberg, Jeanie K., MD
- Hyde, Robert, MD, FACEP
- Ballarin, Daniel, MD
Updated/Reviewed: December 2021