Haemothorax

Last updated 14/06/19

Definition

• Pleural effusion caused by blood
• Defined as the haematocrit of the fluid exceeding half of the peripheral blood

Features

• If occurs concurrently with a pneumothorax = haemopneumothorax
• Tension haemothorax occurs with a massive accumulation of blood causing ipsilateral lung compression and mediastinal displacement
• Usually self limiting
• Typically diagnosed on imaging rather than clinically

Causes

• Trauma
• Blunt or penetrating
• Aortic rupture
• Myocardial rupture
• Hilar injury
• Lung parenchymal injury
• Injury to internal mammary vessels
• Spontaneous
• Intrathoracic malignancy
• Thoracic wall
• Sarcoma
• Hepatocellular with mets
• Aortic dissection
• AV malformations
• Thoracic endometriosis
• Pulmonary infarction
• Bleeding diathesis

Associated Signs & Symptoms

• Most small to moderate haemothoraces are not clinically detectable
• Dullness to percussion
• Reduced breath sounds
• Decreased chest expansion
• Mediastinal shift: massive haemothorax

Risk Factors

• Rib fractures
• Bleeding diathesis

Complications

• Tension haemothorax
• Retained haemothorax
• Blood clots and will not be drained via chest tube
• Increased risk of empyema
• May organise and fibrose: chronic fibrothorax
• Empyema
• Pneumonia
• Acute Respiratory Distress Syndrome (ARDS)
• Hypovolaemic (haemorrhagic) shock
• Usually associated with >1500mls
• In adults <750ml usually well tolerated
• Death
• Great vessel or cardiac injury >50% mortality (rapid)

Differential Diagnosis

• Other causes of pleural effusion
• Haemopneumothorax

Investigations

• Vitals
• BP: hypotension: shock
• Pulse oximetry: hypoxia
• FBE
• Coagulation studies
• Group and Hold
• Imaging
• CXR
• Appears as a pleural effusion
• Very difficult to determine type of effusion
• <200ml difficult to see
• <300ml may not be evident
• In erect patient meniscus line seen
• In average adult patient takes 400ml+ to obscure costo-phrenic angle
• In supine patient diffuse opacification seen




CXR with diffuse opacification


CXR with meniscus

• Ultrasound
• Sensitivity 92%, specificity 100% - in context of trauma
• Redued in the presence of pneumothorax
• Homogenous echogenic effusion
• Plankton sign: swirling internal echoes within effusion
• Detects smaller volumes than CXR
• Hematocrit sign




US haemothorax

• CT Chest
• More sensitive than CXR
• Should differentiate type of effusion
• Associated injuries: pulmonary contusion, lacerations, rib fractures




CT (lung view) of haemothorax

Management

• If traumatic apply primary and secondary survey (DRS ABCDE)
• Look for other associated injuries
• IV access x2 large bore
• O2 15L via non-rebreather mask or HFNP
• Draingage
• Most are self limited and only require drainage
• <300ml may be left alone with absorption over several weeks
• Intercostal Catheter (ICC)
• Removal of blood from pleural space may allow better opposition of pleural surfaces and provide some tamponade
• Generally will require large bore to prevent clot obstruction: 28F+
• 32F or 36F preferable
• If simple haemothorax (no pneumothorax) place posteriorly
• Higher risk of obstruction and tension
• If haemopneumothorax or ventilated place anteriorly
• Video-Assisted Thorascopy (VATS)
• +/- Pleurodesis
• Thoracotomy
• Required <10% patients - typically penetrating trauma with vascular injury
• Indicated if initial drainage >1000mls or >250mls per hour for 3hrs from single side
• Usually within first 3-7 days

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References

1. Lloyd G. Thoracic Trauma. RCEM Learning. 08/05/2017
2. Mahoozi H, Volmerig J, Hecker E. Modern Management of Traumatic Hemothorax. Journal of Trauma & Treatment. 2016;5:326
3. Chest Trauma: Haemothorax. Trauma.org. 02/02/2004
4. Carrol D, Weerakkody Y. Hemothorax. Radiopaedia
5. Traumatic Hemothorax. Core EM
6. Legome E. Initial evaluation and management of blunt thoracic trauma in adults. UpToDate. 11/02/2019