Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Hemothorax Treatment & Management

  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: Jeffrey C Milliken, MD  more...
 
Updated: Dec 17, 2015
 

Approach Considerations

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.

If chest radiography shows that a hemothorax is large enough to obscure the costophrenic sulcus or is associated with a pneumothorax, it should be drained by tube thoracostomy. In cases of hemopneumothorax, placement of two chest tubes may be preferred, with the tube draining the pneumothorax placed in a more superior and anterior position. (See the video below.)

Insertion of chest tube. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

Surgical exploration in cases of traumatic hemothorax should be performed in the following circumstances:

  • Evacuation of more than 1000 mL of blood immediately after tube thoracostomy; this is considered a massive hemothorax
  • Continued bleeding from the chest, defined as 150-200 mL/hr for 2-4 hours
  • Repeated blood transfusion is required to maintain hemodynamic stability

The late sequelae of hemothorax, including residual clot, infected collections, and trapped lung, require additional treatment and, most often, surgical intervention.

Retained clot (defined as an undrained collection of 500 mL or more as estimated by computed tomography [CT] or opacification of one third or more of the chest on chest radiography) is a well-known sequela after initial tube thoracostomy for hemothorax and should be evacuated early in the patient's hospital course, if the clinical condition permits. Early intervention in the case of a retained clot can be performed with thoracoscopy, provided that the operation is planned within 1 week of the bleeding episode.

Empyema usually develops from superimposed infection in a retained collection of blood. It requires surgical drainage and, possibly, decortication.

Fibrothorax is a late uncommon complication that can result from retained hemothorax. Thoracotomy and decortication are required for treatment.

Needle aspiration of a hemothorax is generally not indicated for definitive treatment. Even in cases of nontraumatic hemothorax that are not identified until diagnostic needle aspiration is performed, complete evacuation of these collections often requires treatment with tube thoracostomy, similar to hemothoraces resulting from other causes.

Next

Emergency Department Care

Initial treatment is directed toward cardiopulmonary stabilization and evacuation of the pleural blood collection. 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 hypotensive, establish a large-bore intravenous line. Immediately commence appropriate fluid resuscitation (eg, with 20 mL/kg of lactated Ringer solution), including blood transfusion as necessary.

Evaluate for the possibility of tension pneumothorax. Needle decompression of a tension pneumothorax may be necessary.

The need for a chest tube in an asymptomatic patient is unclear, but if the patient has any respiratory distress, perform thoracostomy. 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.

Previous
Next

Tube Thoracostomy

Tube thoracostomy drainage is the primary mode of treatment for hemothorax. In cases of trauma, patient assessment should be performed using the advanced trauma life support (ATLS) protocol before tube thoracostomy for hemothorax.

This procedure is relatively contraindicated when significant pleural adhesions are known to be present. Incomplete drainage or inability to effectively access the area is likely. Also, blunt division of pleural adhesions may cause additional bleeding and result in lung laceration. If evacuation of such collections is mandated clinically, thoracotomy with division of adhesions under direct vision is the safer approach.

Drainage in patients with coagulopathy

Although not contraindicated, drainage of hemothorax or any pleural effusion in an individual with a coagulopathy should be performed with great care. This group includes patients receiving anticoagulation therapy and those with significant liver disease or inherited coagulation factor deficiencies. Normalization of coagulation function by cessation of anticoagulants or correction of factor deficiencies using appropriate blood products, if necessary, should be initiated before a drainage procedure, if possible.

Needle aspiration should not be performed if clotting deficiencies are present. Rather, tube thoracostomy should be used, with the ability to visualize and control any chest wall bleeding that is encountered. If necessary, in individuals requiring long-term anticoagulant therapy, this medication can be resumed 8-12 hours after the thoracostomy has been completed.

Equipment

A tube thoracostomy tray or kit should be readily available in every hospital emergency department. In adult patients, large-bore chest tubes (usually 36-42 French) should be used to achieve adequate drainage. Smaller-caliber tubes are more likely to occlude. In pediatric patients, chest tube size varies with the size of the child. In patients older than 12 years, the chest tube size used is usually the same as that for adults. In smaller children, a 24- to 34-French chest tube should be used, depending on the size of the child.

Procedure

Although tube thoracostomy may be performed rapidly in some circumstances, sterile technique should always be employed. The insertion site should also be infiltrated with a local anesthetic.

On insertion, the thoracotomy tube is directed toward the costophrenic angle. Attention should be given to the location of insertion on the chest wall and the intrathoracic position of the tube as seen on the chest radiograph. For maximum drainage, thoracostomy tube placement for hemothorax should ideally be in the sixth or seventh intercostal space at the posterior axillary line. In the supine trauma victim, a common error in chest tube insertion is placement too anteriorly and superiorly, making complete drainage very unlikely.

Follow-up

After tube thoracostomy is performed, a repeat chest radiograph should always be obtained immediately. This helps identify chest tube position, helps determine completeness of the hemothorax evacuation, and may reveal other intrathoracic pathology previously obscured by the hemothorax.

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.

If drainage is incomplete as visualized on the postthoracostomy chest radiograph, placement of a second drainage tube should be considered. Preferably, a video-assisted thoracic surgery (VATS) procedure should be undertaken to evacuate the pleural space.

As many as 70-80% of individuals who sustain traumatic hemothorax are successfully treated by tube thoracostomy drainage and require no further therapy. Obtain at least one or two additional chest radiographs over a period of 1-2 weeks to confirm that no further intrathoracic collections or abnormalities are present.

The need for further follow-up chest radiographs may be dictated by the presence of other intrathoracic pathology and by additional symptoms and physical findings. Further treatment or follow-up is determined by the nature of any other injuries.

Previous
Next

Video-Assisted Thoracoscopic Surgery

Video-assisted thoracoscopic surgery (VATS) is an alternative treatment that permits direct removal of clot and precise placement of chest tubes. Several centers have used this modality successfully to help identify and control the source of bleeding in a number of cases.[37] In comparison with thoracostomy, VATS is associated with fewer postoperative complications and shorter hospital stays.

Previous
Next

Thoracotomy

Thoracotomy is the procedure of choice for surgical exploration of the chest when massive hemothorax or persistent bleeding is present. At the time of surgical exploration, the source of bleeding is controlled and the hemothorax is evacuated.

Surgical exploration of the chest may be required later in the course of the patient with hemothorax for evacuation of retained clot, drainage of empyema, or decortication. Cases with retained clot can often be treated successfully with a VATS procedure, especially if this is accomplished within 7 days of initial drainage of the hemothorax, but thoracotomy is usually required for adequate empyema drainage or decortication.

In nontraumatic cases of hemothorax resulting from surgically correctable intrathoracic pathology, correction of the underlying disease process and evacuation of the hemothorax should be undertaken. This may include stapling or resection of bullous disease, resection of cavitary disease, resection of necrotic lung tissue, sequestration of arteriovenous malformations, or resection or repair of vascular abnormalities such as aortic aneurysms.[26]

The decision to perform surgical exploration in cases of hemothorax from acute trauma is based on a number of factors, including the volume and persistence of blood loss, the overall hemodynamic state of the patient, and the amount of blood replacement required. (See Approach Considerations .)

Volume resuscitation should be performed according to ATLS protocol and should be continued en route to the operating room. Some forethought must be given to the availability of blood products if needed rapidly.

Anesthesia should be started rapidly, and all maneuvers should be employed to prevent aspiration. Although a double-lumen endotracheal tube is a very useful luxury to have in thoracic surgical cases, it is only absolutely necessary in a few cases and should not be considered unless it can be placed without delaying the operative procedure. Standard endotracheal intubation is adequate in most cases.

At least two secure large-bore intravenous lines must be established before surgery so that fluids and blood products can be administered rapidly if needed. An arterial line should be placed, but central intravenous access is not an absolute necessity, and surgery should not be delayed for such procedures. Pulse oximetry and the end-tidal carbon dioxide value should be monitored during the procedure.

If stability of the spine or other skeletal structures has not been fully determined before exploratory thoracotomy, every effort must be made to maintain proper support and stabilization of these structures when positioning the patient for thoracotomy.

In hemodynamically unstable patients, volume resuscitation must be maintained during the administration of any anesthetic agents because further instability and hypotension may ensue with anesthesia induction.

A dose of intravenous antibiotics should be administered before emergency exploration. Generally, a broad-spectrum cephalosporin is advisable. If thoracoabdominal injury is present and bowel injury is considered, coverage for gastrointestinal tract organisms should be added.

Conservation of patient body temperature in trauma surgery is extremely important. A variety of surface-warming devices are available and can be used to cover the patient, leaving only the operative field open. Warmers should also be used for intravenous crystalloid and blood products. Raising the ambient temperature in the operating room may be necessary. Maintenance of body temperature is extremely important to prevent complications such as coagulopathy and cardiac arrhythmias.

Intraoperative details

In the majority of trauma cases necessitating chest exploration, the bleeding source is from the chest wall, most commonly intercostal or internal mammary arteries. Once identified, these can be easily controlled with suture ligatures in most cases. After control of obvious bleeding and evacuation of clot and blood, a rapid but thorough exploration of the entire chest cavity should be performed.

Unstable rib fractures found at the time of surgery may require some debridement of sharp rib edges to prevent further injury to the lung or adjacent chest wall structures. At some centers, flail segments or extensive rib fractures are stabilized with wires or other types of support in an attempt to improve postoperative chest wall mechanics.

A thoracic surgeon should be present or immediately available at the time of emergency thoracic exploration because control of bleeding from difficult areas such as the hilum of the lung, the heart, or the great vessels may require a surgeon with expertise in that field.

Patients with injuries between the level of the nipples and the umbilicus may have injuries in both the chest and abdomen. If surgical exploration is mandated, proper positioning, prepping, and draping of these patients is wise so that access to both cavities is possible.

With the patient prepared in this manner, an unanticipated abdominal bleeding source beneath a ruptured diaphragm found at the time of chest exploration for hemothorax can be addressed more easily. The chest can be rapidly explored to help rule out additional intrathoracic sources, and attention can then be quickly turned to abdominal exploration. This preparation also allows ready thoracic access for clamping the thoracic aorta if hemodynamic instability arises from massive or uncontrolled hemorrhage at the time of abdominal exploration.

Diaphragmatic injuries may be closed from either the thorax or the abdomen. In the acute trauma setting, it is usually closed from the abdomen.

Adequate drainage of the chest after control of bleeding is very important. Because chest drainage tubes are placed under direct vision, the complication of retained hemothorax should occur with extreme infrequency. A minimum of two large-bore chest tubes should be used, with one positioned posteriorly and the other positioned anteriorly. Some surgeons prefer the addition of a right-angled chest tube positioned over the diaphragm.

Postoperative details

Ventilator management should progress according to the individual status of the patient. In cases where no other significant injury or disease process is present, weaning and extubation may proceed in a routine fashion. In more critically ill patients such as those with severe chest wall injuries or those requiring massive transfusion, ventilator management must be tailored to the condition of the patient.

After extubation, pulmonary toilet and adequate pain control are critical in preventing pulmonary complications such as atelectasis and pneumonia.

Chest tubes are maintained on underwater seal suction, and the volume of drainage and air leak are noted and recorded daily. If pulmonary injury is found or resection of lung tissue is required at the time of surgery, chest tubes are not removed until any air leak has disappeared and the lung is fully expanded as viewed on the chest radiograph. Drainage should be less than 100 mL in 24 hours before chest tube removal.

Antibiotic coverage begun preoperatively should be discontinued after 48 hours unless a definite reason exists for continuance.

Ventilator management should progress according to the individual status of the patient. In cases in which no other significant injury or disease process is present, weaning and extubation may proceed in a routine fashion. In more critically ill patients, such as those with severe chest wall injuries or those requiring massive transfusion, ventilator management must be tailored to the condition of the patient. After extubation, pulmonary toilet and adequate pain control are critical in preventing pulmonary complications such as atelectasis and pneumonia.

Previous
Next

Management of Retained Clot

Approximately 20% of patients who initially have tube thoracostomy for drainage of hemothorax will have some amount of residual clot in the thoracic cavity. Some controversy exists regarding the management of retained clot after tube thoracostomy. Opinions range from conservative watchfulness to additional chest tube placement to surgical evacuation. Current opinion seems to favor some form of clot evacuation.

Many trauma centers are moving away from additional tube thoracostomy and, instead, advocating an early VATS procedure. This is usually performed within 7-8 days of the initial injury and, in some centers, is performed within 48-72 hours if a retained clot is identified within the thorax.[38, 39, 40, 41] However, VATS may be successful even in patients presenting late after injury.[42]

For VATS evacuation of the hemothorax or retained clot, one-lung ventilation is not required. A single-lumen tube can be used with directions to the anesthesiologist to decrease tidal volume or intermittently hold ventilation during the procedure. If cardiac, great vessel, or tracheobronchial injury is found, conversion to thoracotomy can be performed expeditiously.

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 it shortens the total hospital stay when compared with more conservative management methods.

Patients undergoing surgical intervention for retained hemothorax in either an acute or late setting are monitored in the same fashion as any patient who has undergone VATS or thoracotomy. Generally, the chest tube is removed when drainage is less than 100-150 mL in 24 hours. A chest radiograph is often obtained after removal. Additional chest x-rays films are obtained as previously noted. Care of the thoracic incision(s) is the same as for any thoracic surgical case.

If conservative management of retained collections is chosen, serial chest x-rays should be obtained to assure that resolution is occurring. Once the pleural collection has resolved, a recurrence is unlikely and the patient may be discharged. Increase in size of the collection, development of an air-fluid level, or the new onset of symptoms (eg, fever, cough, dyspnea, pleuritic pain) may warrant CT evaluation and reassessment for surgical intervention.

Previous
Next

Intrapleural Fibrinolysis

Intrapleural instillation of fibrinolytic agents is advocated in some centers for evacuation of residual hemothorax in cases in which initial tube thoracostomy drainage is inadequate. The proposed dose is 250,000 IU of streptokinase or 100,000 IU of urokinase in 100 mL of sterile saline.[43] Some centers prefer the use of tissue plasminogen activator (TPA).[44]

In a study of intrapleural fibrinolytic treatment of traumatic clotted hemothorax, daily instillations of fibrinolytic agents into the intrapleural the space for 2-15 days resulted in an overall success rate of 92%.[43] Nevertheless, the use of intrapleural instillation of fibrinolytic agents for the evacuation of hemothorax is not likely to become routine, because of the length of in-hospital time required for complete treatment and the risk of untoward effects.

Previous
Next

Complications

Reexpansion pulmonary edema after evacuation of retained hemothorax is a rare reported complication. Associated factors in the development of this problem appear to be hypovolemia and the administration of large amounts of blood products and other volume expanders in the perioperative period.

Empyema can develop if a retained clot becomes secondarily infected. This can occur from associated pulmonary injuries or from external sources such as the penetrating object or missile that caused the original injury or the presence of a long-standing clotted thoracostomy tube.

Fibrothorax and trapped lung develop if fibrin deposition occurs within a clotted hemothorax. This can lead to persistent atelectasis and a reduction of pulmonary function. A decortication procedure may be necessary to permit lung expansion and reduce the risk of empyema.

Previous
 
 
Contributor Information and Disclosures
Author

Mary C Mancini, MD, PhD, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Society of Thoracic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Scanlin, MD Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, Society for Pediatric Research, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Denise Serebrisky, MD Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine; Director, Division of Pulmonary Medicine, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center/North Central Bronx Hospital; Director, Jacobi Asthma and Allergy Center for Children, Jacobi Medical Center

Denise Serebrisky, MD is a member of the following medical societies: American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shreekanth V Karwande, MBBS Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center

Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, SWOG, Western Surgical Association

Disclosure: Nothing to disclose.

Additional Contributors

Charles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler 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, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Jane M Eggerstedt, MD, and Allen Fagenholz, MD, to the development and writing of the source articles.

References
  1. May J, Ades A. Porous diaphragm syndrome: haemothorax secondary to haemoperitoneum following laparoscopic hysterectomy. BMJ Case Rep. 2013 Dec 5. 2013:[Medline].

  2. Tatebe S, Kanazawa H, Yamazaki Y, Aoki E, Sakurai Y. Spontaneous hemopneumothorax. Ann Thorac Surg. 1996 Oct. 62(4):1011-5. [Medline].

  3. Rusch VW, Ginsberg RJ. Chest wall, pleura, lung and mediastinum. In: Schwartz SI, ed. Principles of Surgery. 7th ed. New York, NY: McGraw-Hill; 1999:667-790:

  4. Di Crescenzo V, Laperuta P, Napolitano F, Carlomagno C, Garzi A, Vitale M. Pulmonary sequestration presented as massive left hemothorax and associated with primary lung sarcoma. BMC Surg. 2013 Oct 8. 13 Suppl 2:S34. [Medline]. [Full Text].

  5. Broderick SR. Hemothorax: Etiology, diagnosis, and management. Thorac Surg Clin. 2013 Feb. 23(1):89-96, vi-vii. [Medline].

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

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

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

  9. Ota H, Kawai H, Matsuo T. Video-Assisted Minithoracotomy for Blunt Diaphragmatic Rupture Presenting As a Delayed Hemothorax. Ann Thorac Cardiovasc Surg. 2013 Nov 8. [Medline].

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

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

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

  13. Rousset P, Rousset-Jablonski C, Alifano M, Mansuet-Lupo A, Buy JN, Revel MP. Thoracic endometriosis syndrome: CT and MRI features. Clin Radiol. 2013 Dec 10. [Medline].

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

  15. 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. 2007 Oct. 166(10):1081-2. [Medline].

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

  17. Tantraworasin A, Saeteng S. Massive hemothorax due to intrathoracic extramedullary hematopoiesis in a patient with beta thalassemia hemoglobin E disease. J Med Assoc Thai. 2013 Jul. 96(7):866-9. [Medline].

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

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

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

  21. Tomares SM, Jabra AA, Conrad CK, Beauchamp N, Phoon CK, Carroll JL. Hemothorax in a child as a result of costal exostosis. Pediatrics. 1994 Mar. 93(3):523-5. [Medline].

  22. Jin W, Hyun SY, Ryoo E, Lim YS, Kim JK. Costal osteochondroma presenting as haemothorax and diaphragmatic laceration. Pediatr Radiol. 2005 Jul. 35(7):706-9. [Medline].

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

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

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

  26. Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex thoracic injuries. Surg Clin North Am. 1996 Aug. 76(4):725-48. [Medline].

  27. Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Garcia VF, Bowman LM. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg. 1990 Sep. 25(9):961-5; discussion 965-6. [Medline].

  28. Inci I, Ozcelik C, Nizam O, Eren N, Ozgen G. Penetrating chest injuries in children: a review of 94 cases. J Pediatr Surg. 1996 May. 31(5):673-6. [Medline].

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

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

  31. Parry GW, Morgan WE, Salama FD. Management of haemothorax. Ann R Coll Surg Engl. 1996 Jul. 78(4):325-6. [Medline]. [Full Text].

  32. Miller LA. Chest wall, lung, and pleural space trauma. Radiol Clin North Am. 2006 Mar. 44(2):213-24, viii. [Medline].

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

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

  35. Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol. 2013 Dec 1. 16(6):351-4. [Medline].

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

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

  38. Heniford BT, Carrillo EH, Spain DA, Sosa JL, Fulton RL, Richardson JD. The role of thoracoscopy in the management of retained thoracic collections after trauma. Ann Thorac Surg. 1997 Apr. 63(4):940-3. [Medline].

  39. Liu DW, Liu HP, Lin PJ, Chang CH. Video-assisted thoracic surgery in treatment of chest trauma. J Trauma. 1997 Apr. 42(4):670-4. [Medline].

  40. Mancini M, Smith LM, Nein A, Buechter KJ. Early evacuation of clotted blood in hemothorax using thoracoscopy: case reports. J Trauma. 1993 Jan. 34(1):144-7. [Medline].

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

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

  43. Inci I, Ozçelik C, Ulkü R, Tuna A, Eren N. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax. Chest. 1998 Jul. 114(1):160-5. [Medline].

  44. [Guideline] Department of Surgical Education, Orlando Regional Medical Center. Tissue plasminogen activator in traumatic hemothorax. Available at http://www.surgicalcriticalcare.net/Guidelines/tissue_plasminogen_activator.pdf. Accessed: October 14, 2014.

  45. Chou YP, Kuo LC, Soo KM, Tarng YW, Chiang HI, Huang FD, et al. The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma. Eur J Cardiothorac Surg. 2013 Nov 15. [Medline].

  46. Ernstgård L, Sjögren B, Gunnare S, Johanson G. Blood and exhaled air can be used for biomonitoring of hydrofluorocarbon exposure. Toxicol Lett. 2013 Dec 1. 225(1):102-109. [Medline].

 
Previous
Next
 
Left hemothorax in patient with rib fractures.
Upright posteroanterior chest radiograph of patient with right hemothorax.
Contrast-enhanced CT scan of patient with right hemothorax.
Insertion of chest tube. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.