hematotoraax

2. Introduction
• the occurrence of
hemothorax related to
trauma in the US:
300,000 cases per year
• The management of
hemothorax has been a
complex problem since it
was first described over
200 years ago.
Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex
thoracic injuries. Surg Clin North Am. 1996;76:725–748

3. Introduction
John Hunter (1794)
• intercostal incision &
drainage hemothorax
• an iatrogenic
pneumothorax as a
result of the
procedure was
significant
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

4. Introduction
• By the 1870s, early hemothorax
evacuation by trocar & cannula or by
intercostal incision was considered
standard practice.
• Not long after this, underwater seal
drainage was described by a number of
different physicians.
Rusch VW, Ginsberg RJ. Chest wall, pleura, lung and mediastinum. Schwartz SI, ed.
Principles of Surgery. New York, NY: McGraw-Hill; 1999;667–790.

5. Introduction
• Hemothorax: amount of
bleeding into the
thoracic cavity
• Hemothorax defined as:
– <300 ml bleeding as
minimal
– 300-1000 ml as medium
grade
– >1000 ml as massive
Arif HM, Köksalb E, Civan M, et al. Traumatic hemothorax:
Analysis of 108 cases. J. Exp. Clin. Med., 2013; 30:31-33 m

6. Introduction
• Causes of hemothorax may be:
– lung parenchyma
– all vascular structures in thorax
– heart or abdominal organs with a ruptured
diaphragma.
• most commonly from intercostal vessels &
lung parenchyma (Oğuzkaya, 2003).
Arif HM, Köksalb E, Civan M, et al. Traumatic hemothorax:
Analysis of 108 cases. J. Exp. Clin. Med., 2013; 30:31-33 m

7. MEDLINE database
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

8. Diagnosis
Plain Films
• In the normal unscarred pleural space 
– noted as a meniscus of fluid blunting the
costophrenic angle or diaphragmatic surface &
tracking up the pleural margins of the chest
• As much as 400 mL to 500 mL of blood is
required to obliterate the costophrenic angle as
seen on an upright chest radiograph.
Velmahos GC, Demetriades D. Early thoracoscopy for the evacuation
of undrained haemothorax. Eur J Surg. 1999;165:924 –929.

9. Diagnosis
Plain Films
• In the acute trauma setting, the
portable supine chest radiograph may be
the first & only view available
• ≈ 1,000 mL of blood may be missed
when viewing a portable supine CXR film.
Velmahos GC, Demetriades D. Early thoracoscopy for the evacuation
of undrained haemothorax. Eur J Surg. 1999;165:924 –929.

10. Diagnosis
Ultrasound
• more quickly in circumstances than plain
films or CT
• to document the presence & volume of
a pleural effusion
• when CT is unavailable or if the patient’s
physiology would not permit transport.
Soldati G, Testa A, Pignataro G, et al. The ultrasonographic deep sulcus sign
in traumatic pneumothorax. Ultrasound Med Biol. 2006;32:1157–1163.

11. Diagnosis
CT
• In the initial trauma setting complementary to CXR
• may also be value later for localization &
quantification of any retained collections of clot &
potential empyema within the pleural space. (Level 2)
• Numerous authors suggested for further evaluation
of persistent abnormal CXR findings or px who fail
to progress on the ventilator
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

12. Diagnosis
Primary Video-Assisted Thoracoscopy
• for both primary Dx & Tx
• In stable trauma patients with thoracic
injuries  to identify injuries even before
placement of a chest tube
• shorter hospitalizations or fewer
complications than tube thoracostomy
alone
• In the case of thoracoabdominal wounds,
VATS can identify injuries missed on CT
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

13. Management
1. Regardless of size, should be
considered for drainage (Level 3)
2. Attempt of initial drainage should be
with a tube thoracostomy (Level 3)
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

14. Management
• To assess whether a chest tube provides sufficient drainage 
– monitored hourly & daily (reveal the total bleeding volume)
– daily chest X-ray (to compare reexpansion of lungs)
• Removal technique of chest tubes 
– there is an air intake during the expirium phase of respiration
– tubes were taken off during the late phase of inspirium
• If adequate drainage is not achieved  fibrin deposits accumulate on
the visceral pleura  pleural thickening & trapped lungs
• Empyema due to residual hemothorax is a common late complication.
Arif HM, Köksalb E, Civan M, et al. Traumatic hemothorax:
Analysis of 108 cases. J. Exp. Clin. Med., 2013; 30:31-33 m

15. Management
• The 5th intercostal space in the mid-
axillary line is generally used for most
situations.
• This area is commonly known as the
“safe triangle” bordered by:
– the anterior of latissimus dorsi
– the lateral of the pectoralis major
– a line superior to the horizontal level of the
nipple & an apex below the axilla.
Guidelines for the Insertion and
Management of Chest Drains. www.dbh.nhs.uk

16. Management
Closed tube thoracostomy insertion technique by
Dural:
1. a 2 cm incision through the skin & subcutaneous tissue
just superior & parallel to the caudal rib of the 4th-5th
ICS in the MAL
2. The index finger palpates & widens the incision
3. The chest tube is guided bluntly with the index finger
through the chest wall & advanced over the trocar into
the pleural space.
Dural K, Gulbahar G, Kocer B, Sakinci U: A novel and safe technique in
closed tube thoracostomy. J Cardiothorac Surg 2010, 5:21.

17. Management
3. Persistent retained hemothorax after placement of a
thoracostomy tube should be treated with VATS, not a second
chest tube (Level 1).
4. VATS should be done in the first 3 days to 7 days of
hospitalization to decrease the risk of infection & conversion
to thoracotomy (Level 2).
5. Intrapleural thrombolytic may be used to improve drainage of
subacute (6-day to 13-day duration) loculated or exudative
collections, particularly patients where risks of thoracotomy
are significant (Level 3).
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

18. Evaluation of the Evidence Supporting Early
Operative Management for Retained
Hemothorax
Thoracotomy indications after tube thoracostomy:
1. A diffuse continuing opacity on CXR (hemothorax
is not adequately drained & a thrombosed
hemothorax formed)  A thrombosed
hemothorax must be sugically explored to prevent
a fibrous shell formation and to decrease the risk
of ampyema,
2. In case of hemopericardium or cardiac
tamponade
3. Injuries of aorta & great vessels
Arif HM, Köksalb E, Civan M, et al. Traumatic hemothorax: Analysis of
108 cases. J. Exp. Clin. Med., 2013; 30:31-33

19. Massive Hemothorax
Traditional criteria indicating urgent
thoracotomy:
4. If first drained bloody effusion >
1500 ml (> 20ml/kg)
5. If drained bloody effusion > 200
ml/h (2ml/kg/h) in the first 2-4
hours or 100 ml/h in the first 6-
8 hours
6. If blood pressure ↓, the image of
hemothorax on CXR expands,
despite i.v. volume replacement &
drainage via chest tube
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

20. Massive Hemothorax
• These criteria were developed from expert opinion & not from
prospective trials.
• Submitting these criteria to prospective study would be difficult and
unethical.
• Instead, the evidence to supporting indications for urgent thoracotomy
based on tube thoracostomy output is derived from a variety of
descriptive retrospective studies over the past 30 years.
• Indications for urgent thoracotomy were based on physiology, a
premise is still recommended, and minimum chest tube output amounts
(i.e., 800 mL) which has inflated over time.
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

21. Massive Hemothorax
• Karmy-Jones et al. attempted to define the indications for
urgent thoracotomy more clearly in a multicenter
retrospective trial. They advocated thoracotomy when
total chest tube output exceeded 1,500 mL in a 24-hour
period regardless of the mechanism of injury. In this
series, mortality increased linearly with chest tube
output and the mortality at 1,500 mL was three times
greater than at 500 mL
Karmy-Jones R, Jurkovich GJ, Nathens AB, et al. Timing of urgent
thoracotomy for hemorrhage after trauma: a multicenter study. Arch
Surg. 2001;136:513–518.

22. Fibrinolytics
• Some authors have been able to document clot evacuation
using intrapleural fibrolytics
• it is difficult to gauge the contribution of the fibrolytic
agent made in the success of the evacuation rather than
well-placed drains.
• Currently, fibrinolytic agents would have to be seen as a
second-line agent behind surgical intervention when the
risks of surgery are too great to the patient’s overall
outcome.
Mowery et al. Practice Management Guidelines for Management of
Hemothorax and Occult Pneumothorax . J Trauma. 2011; 70: 510-518

23. Hemothorax in Pediatric
• Development of a massive hemothorax is rare in
children and is most associated with severe
impactThese injuries must undergo rapid
evaluation and treatment.
• A pneumothorax may coexist with a
hemothorax.
• The pediatric patient may present with early or
late signs of hypovolemic shock.
Guidelines for the Insertion and
Management of Chest Drains. www.dbh.nhs.uk

24. Hemothorax in Pediatric
• should be treated with rapid
replacement of fluids with isotonic
crystalloid solutions.
• prepare for transfusion with the
institution of red blood cell (RBC)
• .
Avarello & Cantor. Pediatric Major Trauma: An Approach
to Evaluation and Management. Emerg Med Clin N Am 25 (2007)
803–836

25. Hemothorax in Pediatric
• The treatment of hemothorax includes a tube
thoracostomy
• The tube needs to be large enough to occupy most of the
intercostal space and should be placed laterally & directed
posteriorly.
• Chest tube size estimated as 4x the ETT size or can be
found on a length-based resuscitation tape
• repeat CXR should be obtained to confirm positioning &
document improvement in lung expansion.
• Indications for thoracotomy include evacuated blood
volumes exceeding 10 to 15 mL/kg of blood, blood loss
that exceeds 2 to 4 mL/kg/hr, or continued air leak.
Avarello & Cantor. Pediatric Major Trauma: An Approach
to Evaluation and Management. Emerg Med Clin N Am 25 (2007)
803–836

26. Martin et al. Results of a clinical practice algorithm for the management of thoracostomy
tubes placed for traumatic mechanism SpringerPlus 2013, 2:642

27. Summary
• plain films are used a screening tool, but additional imaging in the form
of CT is needed in any patient that has persistent radiographic
abnormalities after placement of simple tube thoracostomy.
• The decision to perform early evacuation of retained hemothorax with
VATS technology is likely to greatly diminish the number of patients
who develop the sequelae of empyema and fibrothorax.
• Although it adds an operative procedure to the patient’s management,
this approach provides definitive treatment, while avoiding the
morbidity of a formal thoracotomy, and decreases total hospital stay
when compared with more conservative management methods.

28. References
1. Mowery et al. Practice Management Guidelines for Management
of Hemothorax and Occult Pneumothorax. J Trauma. 2011; 70:
510-518
2. Arif HM, Köksalb E, Civan M, et al. Traumatic hemothorax:
Analysis of 108 cases. J. Exp. Clin. Med., 2013; 30:31-33
3. Guidelines for the Insertion an Management of Chest Drains.
www.dbh.nhs.uk
4. Avarello & Cantor. Pediatric Major Trauma: An Approach to
Evaluation and Management. Emerg Med Clin N Am 25 (2007)
803–836