HAEMOTHORAX

CTPA (with haemothorax)

Hemothorax: There is complete opacification of the right

hemithorax with slight shift of the trachea towards the left.
Fluid is seen tracking up the lateral margin of the thorax (red
arrow). The clue to the diagnosis is the bullet (blue circle)
which, on CT, was seen to lie within the pleural space
General Considerations
o Hemothorax is blood in the pleural cavity: Most often results from trauma to intrathoracic structures
 Exact distinction between a “bloody pleural effusion” and a hemothorax on a chest x ray is not well defined
o Some use a fluid hematocrit >50% to define hemothorax on aspiration
o Clinically - haemothorax patient will be in shock – pulse and BP unstable (tachycardia, severe
hypotension) but pleural effusion patient will have normal pulse and BP. The ABGs will change though.
o You won’t see ribs on the X-ray – blood very dense and pleural effusion lighter
 Etiologies
o Blunt and penetrating trauma: Penetrating trauma usually lacerates a blood vessel especially rib
fractures. 90% are due to injury to the internal mammary or intercostal vessels.
o Primary or metastatic malignancy
o Anticoagulation
o Pulmonary embolism with infarction
o Hemorrhage from another intrathoracic organ
 Thoracic aortic aneurysm
 Aneurysm of the internal mammary artery
o Abdominal pathology
 Pancreatic pseudocyst
 Splenic artery aneurysm
 Hemoperitoneum
o Catamenial
 Rare; related to thoracic endometriosis and episodic hemorrhage into the thorax that coincides
with the patient's menstrual cycle
o Following lung or cardiac surgery
 Physiologic effects of a hemothorax
o The hemithorax can hold up to 4 L of blood, enough for an exsanguinating hemorrhage
o Clotting of blood may occur very quickly
 Upon lysis of the clots, the protein level in the pleural fluid rises, pulling transudative
fluid into the pleural cavity this can result in an even larger pleural effusion
o Empyema can develop if the blood becomes infected
o Fibrothorax develops from fibrinous adhesions that lead to entrapment of the underlying lung
Clinical Findings
 Hx: Pleuritic pain related to the extent of chest wall injury
 Signs: Shock – cardiopulmonary instability: profound hypotension, tachycardia, hypoxemia. Large haemothorax
causes respiratory and circulatory problems.
 Inspection:
 Cold clammy skin – signs of hypovolemia
 External evidence of trauma
 Respiratory distress: Cyanosis, Tachypnea, Dyspnea (from pulmonary compression).
 Extent depends on whether both lungs are affected or not and extent of haemothorax.
 Palpation: Decreased chest expansion on affected side, tracheal deviation depending on amount
 Percussion: Dull percussion note.
 Auscultation: Decreased vocal fremitus & resonance, Decreased air entry or absent breath sounds

Associated Findings
 Rib fractures are the most common chest wall injuries associated with a hemothorax
  Pulmonary contusion and laceration
 Pneumothorax
 Laceration of intercostal or internal mammary artery can produce persistent bleeding

Imaging Findings
 Upright conventional radiograph is usually the study of first choice
o About 350cc is needed to blunt the costophrenic sulcus on the frontal view
o Haziness of affected thorax will occur if supine and a sufficient amount of blood is present
 CT is almost always performed in chest trauma
o Capable of detecting very small amounts of fluid and small pneumothoraces
Treatment
 Resuscitation
o Airway:
 Obstruction with blood or vomitus or secretions – remove from oropharynx by suction
 Aspirations
o Breathing:
 High flow oxygen (10-15L of oxygen/min) via re-breathable face mask
 If a patient is unable to maintain the airway then an oropharyngeal airway can be established
followed by tracheal intubation if there is no cervical spine injury
o Circulation:
 Assess central and peripheral pulses – if a radial pulse is palpable then SBP is >80 and if femoral
or carotid pulse is palpable, SBP is >60mmHg.
 BP, Cap refill,
 2 large bore IV cannulae (14-16gauge – grey or green). A large amount of blood draining from
the chest can destabilise the patient and require urgent replacement into the circulation so IV
access lines should be inserted into the antecubital fossae before a haemothorax is drained.
 Bloods – Grp and crossmatch, CBC – Hb . BP needs to be monitored continuously to assess
adequacy of blood volume replacement.
 IV fluids
 Bleeding bronchus – insert Fogarty catheter to occlude bleeding bronchus
 Catheterisation – input & output charting
 Drainage via Chest tube (aka tube thoracostomy)
o Don’t put a chest tube in until you have blood available due to possible chest decompression.
o One or two chest tubes are usually inserted, especially if the hemothorax is larger than 400cc
o Ideally, chest tube should be low and posterior to fluid and high and anterior for air
o Chest tube inserted to allow drainage of hemothorax preventing it from becoming a tension
pneumothorax. Also allows apposition of visceral and pleural pleura resealing the defect and decreasing
bleeding (venous or arterial).
o Also re-expansion of the lacerated lung compresses torn vessels thus reducing further blood loss
o Drainage allows mediastinal structures to return to the midline relieving compression of the
contralateral lung
o Chest tube size: wide bore tube (more than 28 French) required.
o If there is continuing blood loss – proceed to thoracotomy.
 o Recurrent transfusions are needed to maintain hemodynamic stability
o There is retained clot of 500cc or more
 Intra-pleural instillation of fibrinolytic agents may also be used
o 60% of haemothoraxes are controlled by chest tube and 40% require operative management

 Emergency thoracotomy (Surgical airway) indicated if

o One liter or more is evacuated on chest tube placement
o Persistent bleeding, defined as >200ml/hour over 3 hours

Small hemothorax
Smaller haemothoraces are normally self-limiting, and rarely require operative intervention. The
only diagnostic sign is dullness to percussion, and this is not very reliable. A supine chest x-ray may
show opacification, but may not reveal moderate amounts of blood. FAST or CT is more reliable.
Treatment is placement of a large-calibre basal chest drain. If drainage continues at more than
200 mL/hour, thoracotomy should be considered.

Massive haemothorax
 Up to 1500 mL (one-third of the blood volume) can rapidly accumulate in the chest following blunt
or penetrating chest injury, leading to hypoxia and shock.
 Massive bleeds are more likely to require surgical repair and pulmonary lobectomy.
 Diagnostic signs are hypoxia, reduced chest expansion, absent breath sounds, dullness to chest
percussion, and hypovolaemic shock.
 Treat by inserting a chest drain, correcting hypovolaemia and transfusing blood. If more than
1500 mL of blood is drained initially, or bleeding continues at >200 mL/hour or the patient remains
haemodynamically unstable, surgical referral and thoracotomy are indicated