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 ETIOLOGY 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