Hemothorax: A Review of the Literature

Abstract

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Figure 1.

Patient # 1. Chest X-ray showing multiple L rib fractures. Patient is lying supine, intubated, on mechanical ventilation. The X-ray does not conclusively show a hemothorax.

Figure 2.

Thoracic CT scan, Patient # 1. Patient surprisingly had no significant blood in the left hemithorax, but 800 ml of blood from a right hemothorax was drained via tube thoracostomy.

Figure 3.

Sagittal view of the right upper quadrant and lower right hemithorax. The dark area depicted By the arrow is diagnostic for either fluid or blood in the right hemithorax.

Figure 4.

Chest X-ray showing a massive L hemothorax following blunt trauma from a motor vehicle crash. A tube thoracostomy has already been performed, but the hemothorax is incompletely evacuated.

Figure 5.

CT scan of the chest demonstrating large right hemopneumothorax. Note motion artifact blurring right heart border and thoracic contents