Updated: 12/23/2021

Massive Hemothorax

Review Topic
  • Snapshot
    • A 19-year-old male is brought to the emergency department following a gunshot wound to the chest. According to the first responders, the man was found unresponsive and was quickly intubated in the field. A physical examination demonstrates decreased lung sounds on the right field and a thoracostomy is quickly performed. The chest tube immediately drained 1600 mL of reddish fluid.
  • Introduction
    • Clinical definition
      • rapid accumulation of > 1000mL of blood within the pleural cavity
      • mostly commonly associated with traumatic injury with involvement of the great or hilar vessels
      • can also occur spontaneously (e.g., malignancy)
  • Epidemiology
    • Demographics
      • motor vehicle collisions (MVCs) represent the most common cause of major thoracic injury
      • about 300,000 cases in the U.S. every year
    • Risk factors
      • penetrating chest trauma (e.g., stab or bullet wounds)
      • motor vehicle accidents
      • malignancy
      • blood clotting disorder
    • Pathogenesis
      • trauma to the thoracic cavity leads to bleeding and subsequent blood pooling in the pleural cavity
        • interferes with normal movement of the lungs by preventing normal expansion of the lungs
      • acute systemic blood loss can lead to compensatory measures (e.g., tachycardia and peripheral vasoconstriction)
    • Associated conditions
      • rib fractures
      • pulmonary contusion
      • pericardial tamponade
      • tracheobronchial injury
      • esophageal injury
      • aortic injury
      • pneumothorax
  • Presentation
    • Symptoms
      • dyspnea
      • pleuritic chest pain
      • lightheadedness
    • Physical exam
      • vital sign abnormalities (e.g., hypotension and tachycardia)
      • diminished or absent breath sounds
      • dull lung sounds with percussion
      • collapsed neck veins
      • cyanosis (if large blood loss)
  • Differential
    • Tension pneumothorax
      • distinguishing factor
        • clinical features such as hyperresonnace
        • characteristic imaging findings
    • Flail chest
      • distinguishing factor
        • will see paradoxical movement of the chest wall
  • Treatment
    • Management approach
      • initial management consists of stabilization (e.g., oxygen) and fluid resuscitation with close monitoring for early signs of respiratory compromise
      • operative management is dependent on the extent of bleeding
    • First-line
      • small hemothorax
        • stabilization and expectant management
      • moderate to large hemothorax
        • drainage of blood via large-bore thoracostomy
        • fluid resuscitation
      • if > 1500 mL of blood or > 200 mL/hour, hemodynamic instability, or need for repeated blood transfusions
        • emergency thoracotomy or video-associated thoracoscopic surgery (VATS)
    • Second-line
      • thoracotomy/VATS
        • if continued bleeding or retained blood clots
  • Complications
    • Empyema
      • more likely to occur if there is retained blood within the pleural cavity
    • Fibrothorax
      • formation of scar tissue secondary to pleural irritation from retained blood
    • Atelectasis
    • Pneumonia
    • Pneumothorax
    • Wound infection
    • Hemorrhagic shock and death

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Questions (2)

(M2.PL.17.4799) A 45-year-old male presents to the emergency department by ambulance from a motor vehicle accident. The emergency medical technician states that the patient had been the driver and was hit on the driver’s side while crossing over the intersection. The patient will open his eyes and withdraw from pain and but can only make sounds with no coherent words. The patient’s temperature is 97°F (36.1°C), blood pressure is 98/63 mmHg, pulse is 112/min, and respirations are 24/min with an oxygen saturation of 94% on 15 L/min O2 via a non-rebreather mask. Upon physical exam, you note reduced breath sounds on the left. The patient is stabilized and a chest radiograph is obtained, as shown in Figure A.

What is the most likely pleural fluid finding?

QID: 109319

Grossly black



Lymphocyte count of > 90% of total WBC



Presence of amylase



Protein fluid to serum ratio > 0.5



Triglycerides > 110 mg/dL



M 6 E

Select Answer to see Preferred Response

(M2.PL.17.79) A 24-year-old male is rushed to the emergency department after sustaining several gunshot wounds to the chest. He was found nonresponsive in the field and was intubated en route to the hospital. His vital signs are as follows: temperature is 98.8 deg F (37.1 deg C), blood pressure is 87/52 mmHg, pulse is 120/min, and respirations are 16/min. Physical examination is significant for decreased breath sounds and dullness to percussion over the right lung. A chest radiograph in the emergency department shows a large fluid collection in the right thoracic cavity. After aggressive fluid resuscitation is initiated, an emergent chest-tube was placed in the emergency department. The chest tube puts out 700 cc of frank blood and 300 cc/hr over the next 5 hours. A follow up post-chest tube insertion chest radiograph demonstrates significant residual right hemothorax. Which of the following is the next best step in management of this patient?

QID: 106152

Clamp the chest tube



Place the chest tube to water seal



Remove the chest tube



Open thoracotomy






M 7 D

Select Answer to see Preferred Response

Evidence (3)
Private Note