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Hemothorax

Denise Serebrisky, MD, Assistant Professor, Department of Pediatrics, Albert Einstein College of Medicine; Director, Division of Pulmonary Medicine, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center; Director, Jacobi Asthma and Allergy Center for Children

Updated: Mar 27, 2009

Introduction

Background

Hemothorax is the presence of blood in the pleural space. The source of blood may be the chest wall, lung parenchyma, heart, or great vessels. The condition is usually a consequence of blunt or penetrating trauma. It may also be a complication of several diseases or may be iatrogenically induced.

Upright posteroanterior (PA) chest radiograph of ...

Upright posteroanterior (PA) chest radiograph of a patient with right hemothorax.



Contrast enhanced CT scan of a patient with right...

Contrast enhanced CT scan of a patient with right hemothorax.


Pathophysiology

Normally, the pleural space, which is between the parietal and visceral pleurae, is only a potential space. Air or fluid in the space may compromise lung expansion. Blood in the pleural space can be associated with both hemorrhagic shock and respiratory compromise; it must be effectively evacuated to prevent complications such as fibrothorax and empyema.

Frequency

United States

In a 34-month period at a large level-one trauma center, 2086 children younger than 15 years were admitted with blunt or penetrating trauma; 104 (4.4%) had thoracic trauma.1 Of the patients with thoracic trauma, 15 had hemopneumothorax (26.7% mortality rate), and 14 had hemothorax (57.1% mortality rate). Many of these patients had other severe extrathoracic injuries. Nontraumatic hemothorax carries a much lower mortality rate.

In another series of children with penetrating chest injuries (ie, stab or gunshot wounds), the morbidity rate was 8.51% (8 of 94).2  Complications included atelectasis (3), intrathoracic hematoma (3), wound infection (3), pneumonia (2), air leak for more than 5 days (2), and septicemia (1). Note that these statistics apply only to traumatic hemothorax.

Clinical

History

  • Trauma or recent surgical intervention is usually self-evident.3
  • Occasionally, a hemorrhagic diathesis such as hemorrhagic disease of the newborn or Henoch-Schönlein purpura can lead to spontaneous hemothorax.4,5
  • Internal thoracic artery rupture has been reported in association with Ehlers-Danlos syndrome.
  • A few patients with spontaneous pneumothorax develop hemothorax.6,7
  • Chest pain and dyspnea are common symptoms.

Physical

  • Tachypnea is common; shallow breaths may be noted
  • Findings include diminished ipsilateral breath sounds and a dull percussion note.
  • If substantial systemic blood loss has occurred, hypotension and tachycardia are present.
  • Respiratory distress reflects both pulmonary compromise and hemorrhagic shock.

Causes

  • Trauma
    • Penetrating injuries of the lungs, heart, great vessels, or chest wall are obvious causes of hemothorax. They may be accidental, deliberate, or iatrogenic in origin. In particular, central venous catheter and thoracostomy tube placement are cited as primary causes.8,9,10
    • Blunt trauma of the chest can occasionally result in hemothorax by laceration of internal vessels. However, because of the relatively more elastic chest wall of infants and children, rib fractures may be absent.11,12
  • Hemorrhagic diathesis: Case reports involve associated disorders such as hemorrhagic disease of the newborn (eg, vitamin K-deficiency) and Henoch-Schönlein purpura.13,5,4
  • Congenital cystic adenomatoid malformations: These malformations occasionally develop complications, such as hemothorax.14
  • Pulmonary arteriovenous malformations: These malformations in hereditary hemorrhagic telangiectasia have been reported to cause hemothorax.15
  • Von Recklinghausen disease: A case of massive spontaneous hemothorax has been reported.16
  • Connective tissue disorders
    • Spontaneous internal thoracic artery hemorrhage was reported in a child with type IV Ehlers-Danlos syndrome.
    • Hemothorax has also been reported in association with costal cartilaginous anomalies.17,18,19,20
    • Rib tumors have rarely been reported in association with hemothorax. Intrathoracic rupture of an osteosarcoma of a rib caused hemorrhagic shock in a 13-year-old girl.21
  • Spontaneous pneumothorax: Hemothorax has been noted to complicate a small fraction of these cases. Although rare, it is more likely to occur in young adolescent males and can be life-threatening secondary to massive bleeding.7

Differential Diagnoses

Empyema
Pleural Effusion

Workup

Imaging Studies

Chest trauma is associated with significant morbidity and mortality in the pediatric population.22 The following studies may be indicated in patients with suspected hemothorax:

  • Radiography
    • Plain radiography of the upright chest may be adequate to establish diagnosis by blunting at the costophrenic angle or an air-fluid interface if a hemopneumothorax is present.
    • If the patient cannot be positioned upright, a supine chest radiograph may reveal apical capping of fluid surrounding the superior pole of the lung. A lateral extrapulmonary density may suggest fluid in the pleural space.
  • CT scanning
    • Thoracic CT scanning has a definite role in evaluation, particularly if plain radiography results are ambiguous or initial therapy is inadequate.23
    • CT scanning is particularly helpful in localizing loculated collections of blood.
  • Bedside ultrasonography
    • Even with the use of chest radiography and helical CT, some injuries can remain undetected. In particular, patients with penetrating chest injuries may harbor serious cardiac injury and a pericardial effusion that may be clinically difficult to determine.
    • Bedside echocardiography can provide immediate, accurate information regarding the pericardium and the need for immediate surgery. It can also improve patient outcome.24

Treatment

Medical Care

  • Prehospital care in patients with hemothorax
    • Assess airway, breathing, and circulation. Evaluate for the possibility of tension pneumothorax. Assess vital signs and pulse oximetry. Administer oxygen and establish an intravenous line.
    • Needle decompression of a tension pneumothorax may be necessary.
    • Initial treatment is directed to cardiopulmonary stabilization and evacuation of the pleural blood collection.
    • If the patient is hypotensive, establish a large-bore intravenous line. Commence appropriate fluid resuscitation with blood transfusion as necessary.
    • To evacuate, place a large-bore thoracotomy tube directed toward the costophrenic angle.
    • If a conventional chest tube is not removing the blood collection, further steps may be necessary. Conventional treatment involves placement of a second thoracostomy tube. However, in many patients, this therapy is ineffective, necessitating further intervention.
    • Video-assisted thoracoscopy (VATS) is an alternative treatment that permits direct removal of clot and precise placement of chest tubes. VATS is associated with fewer postoperative complications and shorter hospital stays compared with thoracostomy.
  • Emergency department care
    • The patient should be sitting upright unless other injuries contraindicate this position. Administer oxygen and reassess airway, breathing, and circulation.
    • Obtain an upright chest radiograph as quickly as possible.
    • If the patient is hemodynamically unstable, immediately commence fluid resuscitation (eg, 20 mL/kg of lactated Ringer solution).
    • The need for a chest tube in an asymptomatic patient is unclear, but if the patient has any respiratory distress, direct the large-bore chest tube toward the costophrenic angle as the chest radiograph indicates.
    • A recent innovation is intrapleural fibrinolytic treatment of traumatic clotted hemothorax. Either 250,000 units of streptokinase or 100,000 units of urokinase was instilled daily into intrapleural space on 2-15 occasions. The overall success rate was 92%.25
    • Finally, if a fibrothorax develops despite previously mentioned therapeutic modalities, a decortication procedure may be necessary to permit lung expansion and reduce the risk of empyema.

Consultations

  • Consult a thoracic surgeon with pediatric experience or a pediatric surgeon in most cases. Literature reviews recommend surgery early in the management of spontaneous hemopneumothorax to reduce associated morbidity.26,27,28
  • In certain cases, consult a pulmonologist.

Medication

  • No data support routine antibiotic coverage of chest tubes in patients with hemothorax.
  • Pain control may require intravenous opioid analgesic agents, intracostal nerve blocks around the chest tube site, or both. Low suction should be used on the chest tube.

Follow-up

Further Inpatient Care

  • Monitor the patient with hemothorax clinically and radiographically until pleural blood collection has resolved. In most instances, this requires inpatient management with serial chest radiography. Once the pleural collection has resolved, a recurrence is unlikely and the patient may be discharged.
  • A chest tube is usually put to water seal after the lung is fully reexpanded on radiography, fluid drainage is less than 50 mL in 24 hours, and no significant residual air leak is present. Situations may exist when a chest tube must be clamped. When no recurrence of air or fluid collection occurs on follow-up radiographic studies, the tube is then usually removed. A postremoval radiograph should be obtained.

Complications

  • Empyema occurs in approximately 5% of cases.
  • Fibrothorax occurs in about 1% of cases.

Prognosis

  • The vast majority of patients who survive a hemothorax have a good outcome; however, approximately 15% may show persistent radiographic abnormalities of the pleural space.

Patient Education

  • Most cases of hemothorax are associated with isolated traumatic episodes; however, those few patients who have medical conditions associated with spontaneous hemothorax should be administered the appropriate information to minimize risk of recurrence.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize hemothorax
  • Failure to realize legal consequences of inflicted injury or therapeutic misadventure

Special Concerns

  • Children may have traumatic hemothorax without bony fractures of the chest wall.

Multimedia

Upright posteroanterior (PA) chest radiograph of ...

Media file 1: Upright posteroanterior (PA) chest radiograph of a patient with right hemothorax.

Contrast enhanced CT scan of a patient with right...

Media file 2: Contrast enhanced CT scan of a patient with right hemothorax.

References

  1. Peclet MH, Newman KD, Eichelberger MR, et al. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg. Sep 1990;25(9):961-5; discussion 965-6. [Medline].

  2. Inci I, Ozcelik C, Nizam O, et al. Penetrating chest injuries in children: a review of 94 cases. J Pediatr Surg. May 1996;31(5):673-6. [Medline].

  3. Bohosiewicz J, Kudela G, Koszutski T. Results of Nuss procedures for the correction of pectus excavatum. Eur J Pediatr Surg. Feb 2005;15(1):6-10. [Medline].

  4. Hammoudeh M, Qaddoumi NK. Pleural haemorrhage in Henoch Schonlein purpura. Clin Rheumatol. Dec 1993;12(4):538-9. [Medline].

  5. Huybrechts S, Wojciechowski M, Poot S, Van Reempts P, Ramet J. Hemothorax as presentation of late vitamin-K-deficient bleeding in a 1-month-old infant with homozygous alpha-1-antitrypsin deficiency. Eur J Pediatr. Nov 24 2006;[Medline].

  6. Issaivanan M, Baranwal P, Abrol S, Bajwa G, Baldauf M, Shukla M. Spontaneous hemopneumothorax in children: case report and review of literature. Pediatrics. Oct 2006;118(4):e1268-70. [Medline].

  7. Kim ES, Kang JY, Pyo CH, Jeon EY, Lee WB. 12-year experience of spontaneous hemopneumothorax. Ann Thorac Cardiovasc Surg. Jun 2008;14(3):149-53. [Medline].

  8. Johnson EM, Saltzman DA, Suh G, et al. Complications and risks of central venous catheter placement in children. Surgery. Nov 1998;124(5):911-6. [Medline].

  9. Waddington MS, Mullins GC. Early complication of pediatric central venous cannulation. Paediatr Anaesth. Nov 2005;15(11):1001-5. [Medline].

  10. Lesher AP, Kratz JM, Smith CD. Removal of embedded central venous catheters. J Pediatr Surg. Jun 2008;43(6):1030-4. [Medline].

  11. Nakayama DK, Ramenofsky ML, Rowe MI. Chest injuries in childhood. Ann Surg. Dec 1989;210(6):770-5. [Medline].

  12. Sharma OP, Hagler S, Oswanski MF. Prevalence of delayed hemothorax in blunt thoracic trauma. Am Surg. Jun 2005;71(6):481-6. [Medline].

  13. Sinniah D, Nagalingam I. Hemothorax in the newborn. Clin Pediatr (Phila). Feb 1972;11(2):84-5. [Medline].

  14. Laberge JM, Puligandla P, Flageole H. Asymptomatic congenital lung malformations. Semin Pediatr Surg. Feb 2005;14(1):16-33. [Medline].

  15. Cottin V, Chinet T, Lavole A, Corre R, Marchand E, Reynaud-Gaubert M. Pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: a series of 126 patients. Medicine (Baltimore). Jan 2007;86(1):1-17. [Medline].

  16. Vaziri M, Mehrazma M. Massive spontaneous hemothorax associated with Von Recklinghausen's disease. Ann Thorac Surg. Oct 2006;82(4):1500-1. [Medline].

  17. Propper RA, Young LW, Wood BP. Hemothorax as a complication of costal cartilaginous exostoses. Pediatr Radiol. Apr 1980;9(3):135-7. [Medline].

  18. Tomares SM, Jabra AA, Conrad CK, et al. Hemothorax in a child as a result of costal exostosis. Pediatrics. Mar 1994;93(3):523-5. [Medline].

  19. Jin W, Hyun SY, Ryoo E, et al. Costal osteochondroma presenting as haemothorax and diaphragmatic laceration. Pediatr Radiol. Jul 2005;35(7):706-9. [Medline].

  20. Cowles RA, Rowe DH, Arkovitz MS. Hereditary multiple exostoses of the ribs: an unusual cause of hemothorax and pericardial effusion. J Pediatr Surg. Jul 2005;40(7):1197-200. [Medline].

  21. Osawa H, Yoshii S, Takahashi W, et al. Hemorrhagic shock due to intrathoracic rupture of an osteosarcoma of the rib. Ann Thorac Cardiovasc Surg. Aug 2001;7(4):232-4. [Medline].

  22. Moore MA, Wallace EC, Westra SJ. The imaging of paediatric thoracic trauma. Pediatr Radiol. May 2009;39(5):485-96. [Medline].

  23. Trupka A, Waydhas C, Hallfeldt KK, et al. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma. Sep 1997;43(3):405-11; discussion 411-2. [Medline].

  24. Mandavia DP, Joseph A. Bedside echocardiography in chest trauma. Emerg Med Clin North Am. Aug 2004;22(3):601-19. [Medline].

  25. Inci I, Ozcelik C, Ulku R, et al. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax. Chest. Jul 1998;114(1):160-5. [Medline]. [Full Text].

  26. Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial. Ann Thorac Surg. Nov 1997;64(5):1396-400; discussion 1400-1. [Medline].

  27. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. Jul 2004;78(1):282-5; discussion 285-6. [Medline].

  28. Chang YT, Dai ZK, Kao EL, Chuang HY, Cheng YJ, Chou SH. Early video-assisted thoracic surgery for primary spontaneous hemopneumothorax. World J Surg. Jan 2007;31(1):19-25. [Medline].

  29. Kosumi T, Yonekura T, Owari M, Hirooka S. Late-onset hemothorax after the Nuss procedure for funnel chest. Pediatr Surg Int. Dec 2005;21(12):1015-7. [Medline].

  30. Tatebe S, Kanazawa H, Yamazaki Y, et al. Spontaneous hemopneumothorax. Ann Thorac Surg. Oct 1996;62(4):1011-5. [Medline].

Keywords

hemothorax, pleural space, trauma, blood in the pleural space, fibrothorax, nontraumatic hemothorax, spontaneous hemothorax, hemopneumothorax, pneumothorax, congenital cystic adenomatoid malformations, CCAM, hemorrhagic shock, respiratory compromise, empyema, treatment, diagnosis, atelectasis, intrathoracic hematoma, wound infection, pneumonia, septicemia, Henoch-Schönlein purpura, Ehlers-Danlos syndrome, spontaneous pneumothorax, chest pain, hemorrhagic disease of the newborn, vitamin K-deficiency, Von Recklinghausen disease, connective tissue disease, osteosarcoma

Contributor Information and Disclosures

Author

Denise Serebrisky, MD, Assistant Professor, Department of Pediatrics, Albert Einstein College of Medicine; Director, Division of Pulmonary Medicine, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center; Director, Jacobi Asthma and Allergy Center for Children
Denise Serebrisky, MD is a member of the following medical societies: American Thoracic Society
Disclosure: Nothing to disclose.

Medical Editor

Thomas Scanlin, MD, Chief, Division of Pediatric Pulmonary & Cystic Fibrosis, Assistant Professor, Department of Pediatrics, Robert Wood Johnson University Medical Group
Thomas Scanlin, MD is a member of the following medical societies: American Thoracic Society and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Charles Callahan, DO, Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center
Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Allen Fagenholz, MD, to the original development and writing of this article.

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