Hemothorax

Background

Lobes of the lung with related anatomy.

Pleural cavity normally a potential space, in which blood collects in a hemothorax.

• Each hemithorax can hold 40% of circulating blood volume

Clinical Features

• Diminished or absent breath sounds
• Dullness to percussion

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Evaluation

CXR with large right sided hemothorax (and widened mediastinum).

Ultrasound scan of the chest showing a left-sided hemothorax.

CT chest of right sided hemothorax.

• CXR
  • Upright - Fluid collections >200-300cc can usually be seen
  • Supine - Fluid collections >1000cc can be missed
  • Mainstem bronchus intubation can appear like a hemothorax on CXR
• US
• CT is gold standard

Management

• Tube thoracostomy
  • Evacuation of 1000-1500mL of blood immediately or 200mL/hr x 4hr = consider thoracotomy
• Autotransfuse lost blood if possible

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Traumatic pneumothorax Traumatic hemothorax ("any acute hemothorax visible on chest radiograph") Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Trauma/bleeding (hemothorax/hemopneumothorax) Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Empyema	Thick pus

Disposition

• Admit

See Also

• Thoracic trauma
• Traumatic pneumothorax
• Spontaneous pneumothorax
• Tension pneumothorax