This document discusses various types and causes of hemothorax. It defines hemothorax as blood in the pleural space and lists trauma, medical conditions, and iatrogenic causes. Treatment options discussed include tube thoracostomy for drainage, VATS for bleeding control, and CT-guided arterial embolization. Complications like clot retention, empyema, and fibrothorax are described. Nontraumatic causes such as malignancy, anticoagulation therapy, and endometriosis are also summarized.

1. Dr. Chandan Kumar Sheet
P. G. Student,
Dept. of Pulmonary Medicine
VIMSAR,Burla,Odisha,India

2.  Definition - Presence of significant amount of blood in the
pleural space
 Causes-
Trauma - Penetrating Medical- Pulmonary embolism
- Non penetrating - Ruptured aortic aneurism
- Iatragenic
- CVC in Subclavian/Jugular vein
- Trans lumber aortography
 Source of blood
- Chest wall
- Lung
- Mediastinum
- Diaphragm
 Blood entering the pleural space coagulate rapidly and defibrinated due
to physiologic movement of heart & lung.
 Loculations occur early

3. Traumatic hemothorax
 High incidence in blunt chest trauma
 Hemothorax most common with displaced rib #
 Concomitant occurrence of hemothorax
& pneumothorax is common whether the
trauma is blunt or penetrating
 Diagnosis –
Demonstration of PLEF by CXR/USG/CT scan
 Treatment – Immediate ICT insertion
- VATS
- Arterial embolisation
 Occult hemothorax - hemothorax seen in CT scan but not in CXR.
-Tube thoracostomy not required

4. Tube thoracostomy
 Indication - diaphragmatic dome is obscured or
- fluid >2cm in thickness in lateral decubitus CXR
 Conditions indicating immediate ICT
- Cardiac temponade
- Continued pleural hemorrhage
- Vascular injury (initial chest drain if >1500 ml )
- Pleural contamination
- Debridement of devitalized tissue
- Sucking chest wound
- Major bronchial air leak
 Size of ICT- Large bore (24 to 36 F)
 Site - high ICS (4th or 5th ) at MAL as diaphragm may be elevated by
trauma

5. Tube thoracostomy…cont..
 Removal of ICT- as soon as they stop draining or cease to
function as it can cause infection
 Advantages of immediate ICT
- Allow complete evacuation of blood
- Stops bleeding from pleural lacerations (if present)
- Easy to quantitate the amount of bleeding
- Decrease incidence of empyema (blood is a good conductor
of infection )
- Blood may be auto transfused
- Rapid evacuation of blood decreased incidence of fibrothorax

6. VATS
 Indications- no precise criteria available but
- If Bleeding >200 ml/hr & no signs of slowing bleeding
(bleeding is not from misplaced central line should be ensured)
- Exsanguinating hemorrhage through the chest tube
 VATS is very effective in - Hemodynamically stable patient with
persistent bleeding (villavicencio et al)
- Controlling bleeding from intercostal
vessels with lung lacerations

7. CT guided arterial embolisation
 Patient with persistent bleeding first CECT thorax is done to detect the
injured vessel (exhibit contrast extravasation) then trans catheter arterial
embolization done
Prophylactic Antibiotics
 Role of prophylactic antibiotics for prevention of empyema in patient of
Tube thoracostomy in hemothorax is unclear.
 A Study done by Maxwell et al showed that
- 1.3% patient with antibiotics developed empyema
- 5.6% patient receiving no antibiotics developed empyema
 Longer duration of ICT & high thoracic trauma score associated with
higher incidence of empyema

8. Autotransfusion
 Barriot et al showed that pre hospital auto transfusion (in ambulance)
may prevent death in life-threatening hemothorax.
 They developed a system containing a 28-30 F ICT with auto-
transfusion device (750 ml bag with filter).
 The blood drains by gravity to ICT bag then re-transfused without
anticoagulant into a central line.
During transfer to the hospital 18 patient received 4.2 ± 0.6 L of
autotransfusion 13 patient survived with out complications

9. Complications of Hemothorax
 Clot Retention(3%)
 Pleural infection (3 to 4 %)
 Pleural effusion (13-34%)
 Fibrothorax(<1%)

10. Clot Retention
 In spite of ICT drainage some amount of blood may retain in
pleural space and leads to complications
 CXR - may misleading hemothorax with suspected clot retention
 CT scan - should be perform before surgical removal of clot
 If clot retention is diagnosed three question need to be asked
1)Clot removal needed or not?
2)When to remove?
3)How to remove?
 Indication of clot removal-
If the clot occupy atleast 1/3 of involved hemithorax 48 to 72 hrs after
initial ICT it should be removed

11. Clot Retention..cont..
 How to remove-
- Thoracoscopy (best method 48-72 hrs. after initial injury)
- VATS (optimal method)
- 2nd chest tube insertion (failure is high, eventually require
thoracoscopy or thoracotomy)
- Intra pleural fibrinolytics- (not recommended)
- more expensive than thoracoscopy
- longer hospitalization than thoracoscopy
- Hypoxemic respiratory failure
 When to remove-
between 48-72 h0urs (optimal time)
 Complications
- Retained collection - Persistent pleural drainage
- Air leaks - Empyema
- Fibrothorax

12. Post traumatic empyema
 Prevention - strict sterile technique during ICT
- Ensuring good apposition between both pleura
(no space to accumulate the fluid or blood)
 Risk factor
- Presence of BPF
- Pulmonary contusion
- Residual clotted haemothorax
- Gross contamination of pleural space during injury
- Patient with shock
- Patient with associated abdominal injury
- Prolonged pleural drainage
 Antibiotic administration reduced chance of empyema

13. Post hemothorax PLEF
 PLEF are common after ICT in hemothorax
 Wilson et al reported that
- 13% patient with out any residual blood developed
PLEF after ICT removal
- 34% patient with residual blood developed PLEF after discharge
 In This situation diagnistic thoracocentesis should be done to rule out
infection.
If no infection present no treatment required

14. Fibrothorax
 Diffuse pleural thickening producing fibrothorax irrespective of residual
blood in pleural cavity
 Takes weeks to months after the hemothorax
 Occurs in <1% of cases
 More common in - hemopneumothorax
- pleural infection
 Treatment - Decortication (definitive treatment)

15. Iatragenic Hemothorax
 Causes-
- Central venous catheterization
- Injury during trans lumber aortography
- Thoracocentesis
- Pleural biopsy
- Swan-Ganz catheterization
 Rare cause
- percutaneous lung aspiration or biopsy
- trans bronchial biopsy
- sclerotherapy in esophageal varices
- In ICU- common following invasive procedure in patient with CRF
 Treatment - ICT

16. Non traumatic hemothorax
Cause
-Malignant pleural disease (most common)
- schwanomma of von recklinghausen disease
- Sarcoma
- angiosarcoma
- HCC
- Anticoagulant therapy in PE
- Catamenial haemothorax
- Bleeding disorder- hemophilia, thrombocytopenia
- Complication of spontaneous pneumothorax
- Rupture thoracic aorta, aneurismal tear, rupture pulmonary AV
fistula, rupture PDA, rupture coaractation of aorta,
-Intrathoracic extramedullary haematopoiesis
-Chicken pox pneumonia
-Bronchopulmonary sequestration
-Unknown cause

17. Nontraumatic hemothorax..cont..
 Diagnosis- Pleural fluid Haematocrit - > 50% of blood
Or
Pleural fluid RBC > 50% of blood
o [a rough estimation of haematocrit can be obtained by pleural fluid
RBC/1,OO,OOO ]
o [ hematocrit <5 % in pleural fluid may look like blood]
 Treatment
- ICT
- thoracotomy / VATS- [If bleeding >100ml/ hr]
- Angiographic embolization [if bleeding from intercostal artery]

18. Hemothorax complicatind
anticoagulant therapy
 Occurs mainly in treatment of pulmonary embolism
 Drugs responsible
-heparin
-warfarin
-enoxaparin
 Hemothorax is apperent 4-7 days of initiation of treatment mainly
 Treatment
- Discontinuation of anticoagulant
- Immediate ICT

19. Catamenial Hemothorax
 Unusual
 Occurs in conjunction with menstruation
 Associated with endometriosis
 Rt hemithorax almost always involved
 Diaphragmatic fenestration and pleuro-peritonial communication
demonstrated in some patient
 Most patient have pleural endometriosis
 Treatment
- Suppression of ovulation by-OCP, progesterone
- Suppression of gonadotrophin by –danazole, GnRH
- Pleurodesis [if hormonal therapy fails]
- THBSO

20. Spontenious Hemopneumothorax
 Most common cause of non traumatic hemopneumothorax
 Different study shows that 3.8% to 6.6 % patients of spontaneous
pneumothorax have hemopneumothrax
 Sourse of bleeding-
-Aberrant vessels
- Torn parietal pleura
- Torn vascular adhesion band from parietal pleura
- Vascular bleb
 Treatment-
-VATS – if bleeding >100ml/hr or hypotension

21. THANK YOU….