Hemothorax

Background

• Each hemithorax can hold 40% of circulating blood volume

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragm injury
  • Hemothorax
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac contusion
  • Cardiac trauma
  • Cardiac tamponade
  • Commotio cordis
    • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Flail chest
  • Rib fracture
  • Scapula fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Traumatic asphyxia

Evaluation

• CXR
  • Upright - Fluid collections >200-300cc can usually be seen
  • Supine - Fluid collections >1000cc can be missed
  • Mainstem bronchus intubation can appear like a hemothorax on CXR
• US
• CT is gold standard

Management

• Tube thoracostomy
  • Evacuation of >1500mL of blood immediately or 200mL/hr x 4hr = consider thoracotomy
• Autotransfuse lost blood if possible

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Traumatic pneumothorax Empyema	Bleeding (Hemothorax/hemopneumothorax) Thick pus

See Also

• Thoracic Trauma
• Traumatic Pneumothorax
• Spontaneous Pneumothorax
• Tension Pneumothorax

Authors

Ross Donaldson