Hemothorax: Clinical sciences

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Introduction0:00–0:40

A hemothorax is the collection of blood within the chest cavity, or the pleural space to be more specific. This collection can be a result of direct trauma to the chest, or can occur spontaneously when patients have pre-existing clotting disorders.
It’s important to address the hemothorax in a timely manner to acutely avoid a potentially life-threatening hemorrhage, as well as to avoid chronically the formation of a fibrothorax, which is an organized clot within the chest cavity surrounding and restricting the patient’s lung from expanding.When approaching a patient who presents with signs and symptoms suggestive of a hemothorax, your first step is to do an ABCDE assessment in order to determine if the patient is stable or unstable.

Unstable patient0:40–3:23

If the patient is unstable, you need to secure their airway, obtain IV access, and begin resuscitation, as well as monitor and manage their vital signs.
Next, obtain a quick focused history and physical exam. Unstable patients with hemothorax typically present with dyspnea and chest pain.
Additionally, they might have a history of an underlying cause, such as chest trauma or recent chest or cardiac procedures like thoracentesis or coronary angiography, as well as a history of cancer, potentially causing erosion into great vessels; thoracic aortic aneurysm; or prior clotting disorders or coagulopathy.
On physical examination, you’ll find these patients to be hypotensive and tachycardic. Now, as one side of the chest is full of blood, that lung will be restricted, so you’ll typically find absent unilateral breath sounds.
In addition, since that side has no airflow, you might also notice dullness to percussion and decreased tactile fremitus on the affected side.Okay, because the patient is unstable, you need to act fast!
Start by ordering a chest x-ray, which will reveal fluid within the pleural cavity, and can help you rule out several life-threatening conditions.
Another quick and reliable way to get an idea of what’s going on is an E-FAST examination. E-FAST involves performing an ultrasound at the bedside to examine the chest and abdominal cavity for the presence of any unusual fluid collection, which typically means blood.
If you see fluid within the pleural cavity, suspect a hemothorax.If this is the case, the first thing you want to do is drain the blood by placing a large bore chest tube, 32 French or greater to prevent tube clotting.
Placing the chest tube and releasing the tension will help stabilize most patients. In addition, depending on the severity of the bleed, some patients may need a transfusion.
Lastly, you should get emergent surgical consultation, who will manage resuscitation and decide if surgery is needed, such as to explore the thoracic cavity and look for the source of the bleeding.
Now that unstable patients are taken care of, let’s talk about stable patients. Your first step here is to obtain a focused history and physical examination.

Stable patient3:23–4:01

Similarly to unstable patients, stable ones typically report dyspnea, chest pain, and possibly a history of chest trauma or clotting problems.
When it comes to the physical exam, you can expect to find similar findings as before. So, there could be absent unilateral breath sounds, dullness to percussion, and decreased tactile fremitus on the affected side.
Once you’ve obtained both history and physical examination, you should order labs, including a CBC and INR, as well as a chest x-ray.

Imaging4:01–5:19

If the labs and chest x-ray are normal, you should consider an alternative diagnosis. On the other hand, labs that point to hemothorax include a normal WBC count, low hemoglobin, and possible low platelets or elevated INR.
If you see these lab findings, combined with a chest x-ray that shows opacification of one hemithorax or blunting of one costophrenic angle, suspect the presence of a hemothorax.Now, this isn’t really enough to make a diagnosis of hemothorax, so you should confirm it with a CT scan of the chest.
The CT may show a heterogeneous collection with areas of increased attenuation within the pleural cavity, which is because both fresh and thicker blood clots can attenuate differently on CT.
If the CT is with IV contrast, you may see extravasation. If you see these findings on CT, you have confirmed the diagnosis of a hemothorax.Okay, once the diagnosis of hemothorax is confirmed, start the treatment right away!

Treatment5:19–9:16

As before, start by placing the chest tube to drain the collection. After the chest tube has been placed, obtain a follow-up chest x-ray to see if the hemothorax has resolved.
Now, if this follow-up chest x-ray shows that the hemothorax has been completely resolved and the lung has completely re-expanded, you should admit the patient, and monitor the output from the chest tube, as well as their hemodynamic status.
If the chest tube output is decreasing over the patient’s hospital stay, that’s a good sign. You can consider removing the chest tube based on the appearance and amount of output.
Regarding the appearance, dark red can indicate there’s old blood draining or an ongoing venous bleed, so you can’t remove the tube yet.
Instead, you want to see a serous output that looks like lemonade, or even a serosanguineous output that looks like fruit punch!
Once your output has the right appearance, check the amount. If there’s minimal drainage, which is typically considered less than 300 milliliters over 24 hours, you can remove the chest tube.Here’s a clinical pearl!
Before removing the tube, you need to obtain stable daily chest x-rays showing no reaccumulation, and labs showing stable hemoglobin, to make sure that the decreased output isn’t due to a tube obstruction.
That’s because, sometimes, the chest tube can clot, and thus you won’t see any output, but your patient is actually filling up with blood!
On the flip side, some patients might have worrisome signs after treatment. These include having an initial output over 1.5 liters; increasing chest tube output over hospital stay; and clinical deterioration such as becoming unstable.
In any of these cases, you’ll need urgent surgical consultation to explore the thoracic cavity, look for and control the source of bleeding, as well as evacuate any retained clots.Okay, let’s go all the way back to the follow-up chest x-ray.
If instead of resolving, your patient still shows persistent or retained hemothorax, you should go straight to urgent surgical consultation.
If the patient is an appropriate surgical candidate, they will undergo operative exploration of the chest, with evacuation of the retained clot, and decortication of the lung.
However, not all patients can undergo surgery. For example, a patient might have some medical comorbidities that make general anesthesia too risky.
So, instead of surgery, they’ll get thrombolytic therapy. This involves infusing both tPA and DNAse solution through the chest tube into the chest cavity.
The tPA solution thins the clotted blood so it can drain through the chest tube; while the DNAse solution breaks down the fluid compartments within the chest to ensure the whole hemothorax is drained.
Keep in mind that thrombolytic therapy can only be given if you're sure the bleeding source has stopped.Here’s a clinical pearl!
Any retained blood needs to be evacuated in less than 72 hours, or the pleural inflammation may lead to the formation of an organized clot and a fibrous peel on the visceral pleura, known as fibrothorax.
If this occurs, the patient may develop a trapped lung, meaning that the lung may become unable to expand due to the restrictive pleura.
Alright, as a quick recap… Patients with hemothorax who are unstable should be assessed with a chest x-ray or bedside E-FAST examination.

Review9:16–10:22

They require chest tube placement, transfusion as needed, and emergent surgical consultation. On the other hand, stable patients are evaluated with labs and a chest x-ray first, and confirm with a CT scan.
These patients should then be managed with chest tube placement. Once a tube is in place, a follow-up chest x-ray is obtained.
Patients with drained hemothorax need monitoring. If the tube output is decreasing, it can be removed.
However, if the output is large, increasing, or the patient worsens, call the surgical team for thoracic exploration to control the bleeding and evacuate retained clots.
Finally, patients with retained hemothorax are treated surgically with clot evacuation and lung decortication, or with thrombolytics in patients who can’t undergo surgery and if the bleeding source has stopped.
Hemothorax: Video, Causes, and Symptoms | Osmosis