Hemothorax (HTX)

Hemothorax (HTX)

David Ray Velez, MD

Table of Contents

Definition
Diagnosis
Treatment
Retained Hemothorax

Definition

Hemothorax (HTX): Gas within the Pleural Space Between the Lungs and Chest Wall

Occult Hemothorax: A Hemothorax Seen on CT but Not Visible on Chest X-Ray

  • Minimum Volume Required to Be Seen on Standard Upright Chest X-Ray: 300 cc

Causes

  • Traumatic Hemothorax: Hemothorax Due to Trauma
    • By Far the Most Common Cause
  • Iatrogenic Hemothorax: Hemothorax Due to Medical Interventions (Surgery, Catheter, Biopsy, etc.)
  • Spontaneous Hemothorax: Hemothorax without an Obvious Cause

Size

  • Small (Minimal): < 300-400 cc
  • Medium: 400-1,000 cc
  • Large (Massive): > 1,000 cc (1 L)

Delayed Hemothorax (DHTX): Hemothorax that Develops After Initial Imaging is Negative

  • Predominantly Affect the Elderly

Hemothorax (HTX) 1

Diagnosis

Hemothorax is Most Often Diagnosed on Imaging (CT is the Gold Standard)

Physical Exam Findings

  • Unequal Breath Sounds (Decreased/Absent on the Affected Side)
  • Dullness to Percussion
  • Decreased Chest Wall Movement
  • Tracheal Deviation – Away from the Affected Side
  • Respiratory Distress
  • Tachypnea
  • Hypoxemia
  • Cyanosis
  • Hypotension and Narrow Pulse Pressure

Treatment

General Management

  • Asymptomatic and Small/Occult: Observation
    • Repeat CXR in 6 Hours to Monitor Progression
  • Symptomatic or Medium-Large: Chest Tube
    • *See Thoracostomy Tube (Chest Tube)
    • Preferred Tube Size: 24-28 Fr
    • A Second Chest Tube May Be Required if Not Adequately Draining After Initial Insertion (Not for Retained Hemothorax)

Thoracic Irrigation (Thoracic Lavage)

  • Definition: Irrigation of the Thorax Through the Chest Tube Upon Insertion
  • Reduces the Risk of Retained Hemothorax and Secondary Interventions
  • Irrigation Volumes ≥ 1,000 mL Normal Saline are Preferred – Shown Shorter Hospital Length of Stay

Thoracotomy Indications

  • Initial Loss > 1,500 cc
  • Continual Loss > 200 cc/hr for 4 Hours
    • *Some Say 250 cc/hr for 3 Hours
  • CAUTION: A Dramatic Decrease in Volume Can Be Due to Complete Evacuation but Can Also Occur Due to Clotting within the Chest Tube

Retained Hemothorax

Retained Hemothorax (rHTX) Definition: Hemothorax that Has Failed to Completely Evacuate with Chest Tube Drainage After 2-3 Days

Occurs in 5-10% of Cases – May Be Decreased by Thoracic Irrigation

Risk Factors

  • High Initial Volume of Blood
  • High Injury Severity Score (ISS)
  • Mechanical Ventilation
  • Multiple Rib Fractures
  • Pneumonia (PNA)
  • Prolonged Time of Chest Tube Drainage
  • Low Hematocrit

Retained Hemothorax is a High Risk of Fibrothorax and Empyema

Management

  • Additional Chest Tubes are Generally Ineffective
  • Should Obtain a CT for Definitive Diagnosis and Evaluation Before Surgery or Fibrinolytic Therapy
  • Video-Assisted Thoracoscopic Surgery (VATS)
    • The Primary Treatment for Retained Hemothorax
    • Surgery Timing: Should Be Done Early within 7 Days (Before Loculations Can Develop)
  • Intrapleural Fibrinolytic Therapy
    • Tissue Plasminogen Activator (tPA) – Activates Plasmin to Breakdown Thrombin and Decrease Fluid Viscosity
      • Regimen:
        • 50 mg tPA in 100 mL NS Instilled into the Chest Tube
        • Chest Tube Clamped for One Hour and Rolled to Distribute
        • Repeat Daily Until Resolved
      • Most Studies Show > 80% Success and < 7% Bleeding Risk
    • Dornase Alfa (DNase/Pulmozyme) – Nebulized to Breakdown DNA and Thin Mucous in Cystic Fibrosis
      • Instilled Through Chest Tubes in Addition to tPA (tPA-DNase) for Parapneumonic Effusions/Empyema
      • No Proven Benefit When Added for Retained Hemothorax (Unless Progressed to Empyema)

Retained Hemothorax with Hematocrit Sign 2

References

  1. Mishra B, Joshi MK, Kumar S, Kumar A, Gupta A, Rattan A, Sagar S, Singhal M, Misra MC. Innocuous cardiac gunshot that proved fatal: A bitter lesson learned. Chin J Traumatol. 2017 Apr;20(2):122-124. (License:  CC BY-NC-ND-4.0)
  2. Palas J, Matos AP, Mascarenhas V, Herédia V, Ramalho M. Multidetector computer tomography: evaluation of blunt chest trauma in adults. Radiol Res Pract. 2014;2014:864369. (License: CC BY-4.0)