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Hemothorax Workup

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

Approach Considerations

Upright chest radiography is the ideal primary diagnostic study in the evaluation of hemothorax. Additional imaging studies, such as ultrasonography and computed tomography (CT), may sometimes be required for identification and quantification of a hemothorax noted on a plain chest radiograph.

In some cases of nontraumatic hemothorax, especially those resulting from metastatic pleural implants, patients may present with the finding of a new pleural effusion of unknown etiology, and hemothorax may not be identified until the initial diagnostic needle aspiration is performed.

Pleural fluid hematocrit

Measurement of the hematocrit of pleural fluid is virtually never needed in a patient with a traumatic hemothorax, but may be indicated for the analysis of a bloody effusion from a nontraumatic cause. In such cases, a pleural effusion with a hematocrit value more than 50% of that of the circulating hematocrit is considered a hemothorax.

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Chest Radiography

Plain radiography of the upright chest may be adequate to establish diagnosis by showing blunting at the costophrenic angle or an air-fluid interface if a hemopneumothorax is present. (See the image below.) 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.

Upright posteroanterior chest radiograph of patien Upright posteroanterior chest radiograph of patient with right hemothorax.

In the normal unscarred pleural space, a hemothorax is noted as a meniscus of fluid blunting the costophrenic angle or diaphragmatic surface and tracking up the pleural margins of the chest wall when viewed on the upright chest x-ray film. This is essentially the same chest radiographic appearance found with any pleural effusion.

In cases in which pleural scarring or symphysis is present, the collection may not be free to occupy the most dependent position within the thorax, but will fill whatever free pleural space is available. This situation may not create the classic appearance of a fluid layer on a chest radiograph.

In the acute trauma setting, the portable supine chest radiograph may be the first and only view available from which to make definitive decisions regarding therapy. The presence and size of a hemothorax is much more difficult to evaluate on supine films. Although as much as 400-500 mL of blood is required to obliterate the costophrenic angle on an upright chest radiograph, as much as 1000 mL of blood may be missed when viewing a portable supine chest x-ray film. Only a general haziness of the affected hemithorax may be noted.

In blunt trauma cases, hemothorax is frequently associated with other chest injuries visible on the chest radiograph, such as rib fractures (see the image below), pneumothorax, or a widening of the superior mediastinum.

Left hemothorax in patient with rib fractures. Left hemothorax in patient with rib fractures.
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Ultrasonography

Trauma ultrasonography is used at some trauma centers in the initial evaluation of patients for hemothorax. 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.[33]

One drawback of ultrasonography for the identification of traumatic hemothorax is that associated injuries readily seen on chest radiographs in the trauma patient, such as bony injuries, widened mediastinum, and pneumothorax, are not readily identifiable on chest ultrasonograms. Ultrasonography more likely plays a complementary role in specific cases where the chest x-ray findings of hemothorax are equivocal.

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Computed Tomography

Thoracic CT (see the image below) has a definite role to play in evaluation, particularly if plain radiography results are ambiguous or initial therapy is inadequate.[34, 35] CT is a highly accurate diagnostic study for pleural fluid or blood and is particularly helpful in localizing loculated collections of blood.

Contrast-enhanced CT scan of patient with right he Contrast-enhanced CT scan of patient with right hemothorax.

In the trauma setting, CT does not hold a primary role in the diagnosis of hemothorax but is complementary to chest radiography. Because many victims of blunt trauma do undergo evaluation with chest CT, abdominal CT, or both, hemothorax not evident on initial chest radiographs might be identified and treated.

Currently, CT is of greatest value later in the course of management of the chest trauma patient, in particular for localization and quantification of any retained collections of clot within the pleural space.

Although multidetector CT allows for the accurate diagnosis of most traumatic injuries, in pediatric patients it should be used in selected cases only. Routine use would result in an unacceptably high radiation exposure to a large number of patients without proven clinical benefit.[36]

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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].

 
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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.
 
 
 
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