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Definition

Haemothorax is a collection of blood in the pleural space and may be caused by blunt or penetrating trauma. Most haemothoraces are the result of rib fractures, lung parenchymal and minor venous injuries, and as such are self-limiting. Less commonly there is an arterial injury, which is more likely to require surgical repair.

Diagnosis

Most small-moderate haemothoraces are not detectable by physical examination and will be identified only on Chest X-ray, FAST or CT scan. However, larger and more clinically significant haemothoraces may be identified clinically. If a large haemothorax is detected clinically it should be treated promptly.

   Trachea
   Expansion
   Percussion Note
   Breath sounds

Physical examination

Chest examination may indicate the presence of significant thoracic trauma with external bruising or lacerations, or palpable crepitus indicating the presence of rib fractures. There may be evidence of a penetrating injury over the affected hemithorax. Don't forget to examine the back!

Multiple stabbing: front Don't forget the back!

The classic signs of a haemothorax are decreased chest expansion, dullness to percussion and reduced breath sounds in the affected hemithorax. There is no mediastinal or tracheal deviation unless there is a massive haemothorax. All these clinical signs may be subtle or absent in the supine trauma patient in the emergency department, and most haemothoraces will only be diagnosed after imaging studies.

Chest X-Ray

Chest X-ray remains the standard test for diagnosis of thoracic trauma in the emergency department. In the erect patient (penetrating injury), the classical picture of a fluid level with a meniscus is seen. Although the erect film is more sensitive, it takes approximately 400-500mls of blood to obliterate the costo-phrenic angle on a chest radiograph.

Haemothorax: Erect Haemothorax: Erect

In the supine position (most blunt trauma patients) no fluid level is visible as the blood lies posteriorly along the posterior chest. The chest X-ray shows a diffuse opacification of the hemithorax, through which lung markings can be seen. It may be difficult to differentiate a unilateral haemothorax from a pneumothorax on the opposite side.

 
Right Haemothorax (supine)  

FAST Ultrasound

It may be difficult to detect small amounts of blood (< 200mls) on the plain chest radiograph. Emergency room ultrasound examination can detect smaller haemothoraces, although in the presence of a pneumothorax or subcutaneous air ultrasound may be difficult or inaccurrate. When examining the right and left upper quadrants, the examiner can usually view above the diaphragms to identify any fluid collections. The significance of small haemothoraces that are not visible on plain films is not entirely clear.

FAST Right Upper Quadrant Examination Haemothorax, diaphragm & liver (Left to Right)

Computed Tomography

Most cases of thoracic trauma do not require computed tomography (CT). CT is more sensitive than the plain chest radiograph in diagnosing haemothoraces. However, CT can be invaluable in determining the presence and significance of a haemothorax, especially in the blunt, supine trauma patient who may have multiple thoracic injuries. Small amounts of blood are detectable and can be localised to specific areas of the thoracic cavity. The significance of CT-only detectable haemothoraces is not entirely clear, and certainly some of these will require no treatment. CT may also be useful in differentiating haemothorax from other thoracic pathology such as pulmonary contusion or aspiration.

CT Haemothorax (massive)

Management

Chest drain

Chest tube placement is the first step n the management of traumatic haemothorax. The majority of haemothoraces have already stopped bleeding and simple drainage is all that is required. All chest tubes placed for trauma should be of sufficient calibre to drain haemothoraces without clotting. Hence the smallest acceptable size for an adult patient is 32F, and preferably 36F tubes should be placed.

Chest Drain

Chest drains for simple haemothorax can be placed posteriorly. However if there is concomitant pneumothorax, or patients have multiple rib fractures with positive pressureventilation, drains should be placed anteriorly to avoid tension pneumothorax for an obstructed chest tube.

Thoracotomy

Thoracotomy is required in under 10% of thoracic trauma patients. Most haemothoraces stem from injury to lung parenchyma or venous injury and will stop bleeding without intervention. Penetrating trauma is more likely to be associated with arterial haemorrhage requiring surgery.

Subsequent thoracotomy

The indications for thoracotomy are usually quoted as the immediate drainage of 1000-1500mls of blood from a hemithorax. However the initial volume of blood drained is not as important as the amount of on-going bleeding. If the patient remains haemodynamically stable they may be admitted and observed. The colour of the blood is also important - dark, venous blood being more likely to cease spontaneously than bright red arterial blood. Patients admitted for observation who have continuing drainage with no signs of reduction in chest tube output over 4-5 hours should also undergo thoracotomy. The threshold for this is usually stated at around 200-250mls of blood per hour.

Complications

Retained Haemothorax, Empyema

Failure to adequately drain a haemothorax initially results in residual, clotted haemothorax which will not drain via a chest tube. If left untreated, these retained haemothoraces may become infected and lead to empyema formation. Even if they remain uninfected, the clot will organise and fibrose, resulting in a loss of lung volume which may result in impaired pulmonary function. Failure to adequately drain a haemothorax is due to failure to initially diagnose the haemothorax or inadequately draining the haemothorax (small chest tube, incorrect placement, clotted tube).

Diagnosis of retained haemothorax is usually made on CT, which shows one or more loculated collections of blood. Surgery is indicated if there is evidence of empyema (fever, raised white cell count, air-fluid levels on CT), or if the haemothorax is large enough to cause lung volume loss. Surgery if possible should be performed early, within the first 3-7 days following injury. At this time the clot can be cleared with thoracoscopy or a mini-thoracotomy. If clot evacuation is delayed beyond this time the inflammatory reaction in the pleura requires a more formal thoracotomy with removal of this 'peel' and often formal decortication - a much longer and bloodier procedure. At this time there is limited evidence to support the use of thrombolytic therapy to lyse clotting haemothoraces.

References

Diagnosis

Feliciano DV, Rozycki GS. 'Advances in the diagnosis and treatment of thoracic trauma.' Surg Clin North Am. 1999;79:1417-29

Rozycki GS, Feliciano DV, Davis TP 'Ultrasound as used in thoracoabdominal trauma.' Surg Clin North Am. 1998;78:295-310

Abboud PA, Kendall J. 'Emergency department ultrasound for hemothorax after blunt traumatic injury.' J Emerg Med. 2003;25:181-4

Ma OJ, Mateer JR. 'Trauma ultrasound examination versus chest radiography in the detection of hemothorax.' Ann Emerg Med. 1997;29:312-5

Management

Parry GW, Morgan WE, Salama FD. 'Management of haemothorax.' Ann R Coll Surg Engl 1996;78:325-326

Retained Haemothorax

Meyer DM, Jessen ME, Wait MA, Estrera AS. 'Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial.' Ann Thorac Surg. 1997;64:1396-400

Vassiliu P, Velmahos GC, Toutouzas KG. 'Timing, safety, and efficacy of thoracoscopic evacuation of undrained post-traumatic hemothorax.' Am Surg. 2001;67:1165-9

Watkins JA, Spain DA, Richardson JD, Polk HC Jr. 'Empyema and restrictive pleural processes after blunt trauma: an under-recognized cause of respiratory failure.' Am Surg. 2000;66:210-4

Velmahos GC, Demetriades D, Chan L et al. 'Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient.' J Trauma. 1999;46:65-70

Inci I, Ozcelik C, Ulku R. 'Intrapleural fibrinolytic treatment of traumatic clotted hemothorax.' Chest 1998;114:160-5

 

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