Professional Documents
Culture Documents
Hemotorax
Hemotorax
KEYWORDS
Hemothorax Thoracic Trauma Video-assisted thoracic surgery
KEY POINTS
Initial management of traumatic hemothorax should focus on identification and treatment of life-
threatening injuries, control of bleeding, and resuscitation.
Retained hemothorax is an important entity in the management of the injured patient, as it predis-
poses to the development of empyema and fibrothorax.
Early video-assisted thoracic surgery is an effective strategy for the management of retained hemo-
thorax after diagnosis.
There are multiple causes of spontaneous hemothorax with which the thoracic surgeon should be
familiar.
are acceptable. Blunting of the costophrenic angle in patients who are not stable enough for trans-
or partial or complete opacification of the hemi- port. A prospective study of the utility of ultraso-
thorax is suggestive of hemothorax. Presence of nography in diagnosing hemothorax in 61 trauma
a small hemothorax may be subtle, as several patients demonstrated sensitivity of 92% and
hundred milliliters of blood can be obscured by specificity of 100%. In most cases the ultrasonog-
the diaphragm and abdominal viscera on upright raphy result was available to the trauma team
films. Similarly, in supine patients blood will layer before the CT results.4
in the pleural space and may appear as little
more than haziness in one hemithorax relative to
Management
the contralateral side. Fig. 1 demonstrates hazi-
ness of the left lung field on a portable supine Tube thoracostomy is the first-line treatment of
chest radiograph obtained during initial trauma most hemothoraces. Appropriate placement of
evaluation; the patient had a large-volume hemo- the tube is critical for effective drainage of the
thorax necessitating exploration and repair of the pleural space. Placement should be directed pos-
subclavian artery. A large hemothorax may opacify teriorly to allow for dependent drainage in the
an entire hemithorax or cause mediastinal shift supine patient. A thoracostomy tube can be safely
and tension physiology. These findings require placed in the sixth or seventh intercostal space at
immediate intervention. the mid-axillary line in most patients by an experi-
Computed tomography (CT) has become enced operator. Historically, larger-diameter chest
commonplace in the evaluation of the injured tubes have been used for suspected hemothorax
patient, and allows for detection of much smaller to prevent clotted blood from obstructing
amounts of fluid than chest radiography. Fluid in drainage. The Advanced Trauma Life Support
the pleural space is assumed to be blood until protocol calls for use of a 36F chest tube in educa-
proved otherwise. If the nature of fluid in the tional materials.5 However, a recent prospective
pleural space is in question (ie, in the case of analysis of size 28F to 32F tubes compared with
chronic pleural effusion), measurement of Houns- 36F to 40F tubes in 293 patients at a level I trauma
field units may prove useful. An arterial blush iden- center demonstrated no difference in outcomes
tified on CT indicates ongoing bleeding and is an based on size of chest tube placed.6 Most
indication for urgent intervention (Fig. 2). Persis- surgeons place 32F or 36F tubes for suspected
tent abnormalities on chest radiographs should hemothorax. When feasible, patients should
be further evaluated by CT, especially in patients receive antimicrobial prophylaxis with cefazolin
who are failing to progress (Fig. 3). before tube thoracostomy. This recommendation
In the past decade the use of ultrasonography is an advisory of a working group of the Eastern
has become a mainstay in emergency department Association for Surgery for Trauma.7
and trauma evaluation. Ultrasonography is often Traditional indications for surgical intervention in
more readily attainable than CT and can be used acute traumatic hemothorax include initial
drainage of more than 1500 mL following tube
thoracostomy or drainage of more than 200 mL
per hour for 4 hours. However, the physiologic
parameters and overall condition of the patient
must be the primary driver for surgical intervention,
rather than absolute volume of initial or ongoing
chest-tube output.
The surgical approach to acute thoracic trau-
matic injury is tailored to the suspected injury
and clinical situation. The standard initial approach
to traumatic hemothorax is the anterior thora-
cotomy. Performed through the fourth interspace,
this approach allows for rapid assessment of intra-
thoracic injuries and temporary hemostasis as
necessary. A right anterior thoracotomy allows
for access to the right atrium, superior vena
Fig. 1. Supine portable chest radiograph of a patient
cava, right lung, right pulmonary hilum, and
obtained during initial trauma evaluation. A large ascending aorta. Left anterior thoracotomy
volume of blood in the pleural space may appear as provides access to the left and right ventricles,
haziness as blood layers posteriorly. The CT scan of pulmonary artery, and left pulmonary hilum. This
this same patient is presented in Fig. 2. approach also provides access for release of
Hemothorax 91
Fig. 2. Contrast CT scan of the patient in Fig. 1. Note the large-volume left hemothorax and contrast blush, indi-
cating need for immediate intervention. This patient had an injury to the left subclavian artery and vein.
Fig. 3. Persistent abnormalities on chest radiographs should be evaluated by CT to assess for retained hemothorax.
In this patient hemothorax developed gradually following blunt chest injury.
92 Broderick
or loculated collections of blood may not be evac- of controls, and difficulty in quantifying resolution
uated by single or even multiple chest tubes. of hemothorax.16 A retrospective comparison of
Retained blood in the pleural space is a risk factor patients treated with intrapleural streptokinase or
for the development of further complications thoracoscopy for the management of retained he-
including empyema9–11 and fibrothorax. The diag- mothorax showed a shorter hospital stay and less
nosis and management of retained hemothorax frequent need for thoracotomy in the thoraco-
after thoracic trauma remains controversial and scopy group.20 Although a prospective compar-
has been the subject of several recent investiga- ison with thoracoscopy is lacking, fibrinolytic
tions in the trauma literature, including a prospec- therapy may serve as a useful adjunct to initial
tive multicenter analysis undertaken by the chest-tube drainage or as an alternative to surgical
American Association for the Surgery of Trauma intervention in patients deemed unfit for more
(AAST).12 invasive procedures.
The presence of retained hemothorax may not Several studies over the past decade have
be readily apparent on routine radiographs. demonstrated the effectiveness of VATS for
Suspicion of inadequate drainage should prompt the management of retained traumatic hemoth-
evaluation by CT imaging. Observation is an orax.15,21,22 The visualization afforded by VATS
acceptable strategy for small collections.13 The allows for thorough inspection and evacuation of
AAST prospective study found that 30.8% of the pleural space, and accurate placement of
patients with retained hemothorax after initial drains to allow for ongoing drainage as necessary.
trauma intervention were managed by observa- VATS was the most common initial management
tion alone. Of these patients, 82.2% required no approach after diagnosis of retained hemothorax
further interventions. On multivariate analysis, in the 2012 AAST study, and patients managed
clinical predictors of successful observation by VATS required no further therapy in 70% of
were initial chest-tube indication of pneumothorax cases.12 The timing of VATS in patients with re-
and CT estimated volume of hemothorax of less tained hemothorax is a matter of debate. However,
than 300 mL.12 it appears that early intervention is generally more
Insertion of a second thoracostomy tube or, successful and less frequently requires conversion
more recently, the use of image-guided drainage to thoracotomy.22–24
is another approach to draining retained hemo- Despite its associated morbidity, thoracotomy
thoraces. These approaches are unlikely to be remains the approach with which the effectiveness
successful in adequately draining loculated or of other interventions must be compared. Thora-
clotted collections. A randomized prospective trial cotomy proved the most effective means by which
by Meyer and colleagues14 compared the use of to treat retained hemothorax in the 2012 AAST
additional chest-tube placement with thoraco- prospective study, with 79% of patients requiring
scopy for evacuation of retained hemothorax after no further intervention. Factors that predicted
initial chest-tube placement. The thoracoscopy eventual need for thoracotomy included associ-
group demonstrated a shorter duration of chest- ated diaphragmatic injury and failure to administer
tube drainage (2.53 vs 4.50 days, P<.02), shorter antibiotics at the time of initial chest-tube
hospital stay (5.40 vs 8.13 days, P<.02), and placement.12
reduced total hospital costs. Furthermore, in the Retained hemothorax puts patients at risk for
2012 AAST prospective trial 64% of patients in development of empyema. A recent study of
whom an additional chest tube was placed 328 trauma patients with retained hemothorax
required subsequent intervention for retained from 20 centers demonstrated an overall inci-
hemothorax; 41% of patients undergoing dence of empyema of 26.8%. Risk factors for
image-guided drainage required subsequent the development of empyema included rib frac-
interventions.12 tures, injury severity score (ISS) greater than
The use of fibrinolytic therapy administered 25, or the need for additional procedures to
through an indwelling chest tube has been exten- address retained hemothorax. Of patients devel-
sively studied for empyema and parapneumonic oping empyema after retained hemothorax,
effusion, for which it has been shown to decrease 94.3% required additional interventions, with
the frequency of surgical intervention.15 The utility many requiring 2 or more interventions beyond
of this modality for retained hemothorax in trauma initial chest-tube insertion. After adjusting for
patients is less evident. Multiple studies in trauma the baseline characteristics, patients who devel-
patients have demonstrated that fibrinolytic oped empyema after retained hemothorax had
therapy can result in effective drainage of the significantly prolonged stays in the intensive
pleural space.16–19 However, analysis of these care unit and hospital in comparison with those
results are plagued by small sample sizes, lack who did not.11
Hemothorax 93
31. Ference BA, Shannon TM, White RI, et al. Life-threat- 39. Yoshida K, Tobe S. Dissection and rupture of the left
ening pulmonary hemorrhage with pulmonary arterio- subclavian artery presenting as hemothorax in
venous malformations and hereditary hemorrhagic a patient with Von Recklinghausen’s disease. Jpn J
telangiectasia. Chest 1994;106:1387–90. Thorac Cardiovasc Surg 2005;53:117–9.
32. Martinez FJ, Villaneuna AG, Pickering R, et al. Spon- 40. Tatebe S, Asami F, Shinohara H, et al. Ruptured
taneous hemothorax: report of six cases and review aneurysm of the subclavian artery in a patient with
of the literature. Medicine 1992;71:354–68. von Recklinghausen’s disease. Circ J 2005;69:
33. Esplin MS, Varner MW. Progression of pulmonary 503–6.
arteriovenous malformation during pregnancy: case 41. Liu SF, Wu CC, Lai YF, et al. Massive hemoptysis and
report and review of the literature. Obstet Gynecol hemothorax caused by pleuropulmonary angiosar-
Surv 1997;52:248–53. coma. Am J Emerg Med 2002;20:374–5.
34. Bini A, Gazia M, Stella F, et al. Acute massive hae- 42. Sohara N, Takagi H, Yamada T, et al. Hepatocellular
mopneumothorax due to solitary costal exostosis. carcinoma complicated by hemothorax. J Gastroenterol
Interact Cardiovasc Thorac Surg 2003;2(4):614–5. 2000;35:240–4.
35. Uchida K, Kurihara Y, Sekiguchi S, et al. Sponta- 43. Caplin JL, Gullan RW, Dymond DS, et al. Hemothorax
neous haemothorax caused by costal exostosis. due to rupture of a benign thymoma. Jpn Heart J
Eur Respir J 1997;10(3):735–6. 1985;26:123–5.
36. Joseph J, Sahn SA. Thoracic endometriosis 44. Yang WM, Chen ML, Lin TS. Traumatic hemothorax
syndrome: new observations from an analysis of resulting from rupture of a mediastinal teratoma:
110 cases. Am J Med 1996;100:164–70. a case report. Int Surg 2005;90:241–4.
37. Bagan P, Le Pimpec Barthes F, Assouad J, et al. Cata- 45. Hsiao CW, Lee SC, Chen JC, et al. Massive sponta-
menial pneumothorax: retrospective study of surgical neous haemopneumothorax in a patient with haemo-
treatment. Ann Thorac Surg 2003;75:378–81. philia. ANZ J Surg 2001;71:770–1.
38. Miura H, Taira O, Uchida O, et al. Spontaneous haemo- 46. Morecroft JA, Lea RE. Haemothorax: a complication
thorax associate with Von Recklinghausen’s disease: of anticoagulation for suspected pulmonary embo-
review of occurrence in Japan. Thorax 1997;52:577–8. lism. Br J Clin Pract 1988;42:217–8.