Thoracic Surgery & Emergency Medicine & Pulmonology
Hémothorax | Clinique Omicron Québec
Hemothorax refers to the accumulation of blood in the pleural space - the virtual cavity between the visceral layer (covering the lung) and the parietal layer (lining the chest wall) of the pleura. Unlike an ordinary liquid pleural effusion (serofibrinous or exudative), the contents are blood - identified by a pleural fluid hematocrit greater than 50 % of the blood hematocrit. The most frequent cause is thoracic trauma (blunt or penetrating), but spontaneous hemothorax occurs in the context of neoplasia, anticoagulation, arteriovenous malformation or thoracic endometriosis. Massive hemothorax - defined as the rapid accumulation of more than 1,500 mL of blood in the pleural cavity - is an absolute surgical emergency, due to a dual mechanism: pulmonary compression leading to respiratory failure, and hypovolemic hemorrhagic shock. In non-emergency situations, the presentation may be more insidious, discovered by chance on a chest X-ray or CT scan performed for another reason. Management is based on thoracic drainage, control of the source of bleeding and prevention of complications: retained hemothorax, secondary thoracic empyema and fibrothorax.
Pathophysiology, causes, and classification
- Anatomy of the Pleural Space and Consequences of Hemothorax Normal pleural space: virtual — contains 5–15 mL of lubricating pleural fluid → negative pressure (−5 to −10 cmH₂O) contributing to lung expansion; blood accumulation: compresses lung parenchyma → atelectasis + hypoventilation + hypoxemia + intrapulmonary shunt + if large volume → contralateral mediastinal shift (rarely as dramatic as in tension pneumothorax) → reduced venous return → obstructive shock; biological consequences of blood in the pleural space: RBCs lyse → hemoglobin + iron → pleural inflammatory reaction → fibrin deposition → organization → clot (clotted hemothorax — retained hemothorax) → if not drained within 48–72h → the clot solidifies → fibrothorax (fibrous membrane trapping the lung → permanent ventilatory restriction) → possible bacterial contamination → pleural empyema (infection of pleural fluid) → sepsis
- Classification by volume and etiological causes: classification by volume: small hemothorax<300 ml) : oblitération du cul-de-sac costo-diaphragmatique sur la radiographie thoracique (visible à partir de ~200 ml en position debout) → souvent résolutif spontanément surveillance + moyen hémothorax (300–1 500 opacité base pulmonaire retentissement ventilatoire modéré drainage indiqué massif (>1,500 mL or active bleeding >200 mL/h × 4h or >1,500 mL over 24h) → surgical emergency → thoracotomy or videothoracoscopy (VATS) for hemostasis; traumatic causes (80-85 % of hemothoraxes): closed thoracic trauma (contusion): road accident + fall + contact sport → rib fractures → laceration of intercostal artery (most frequent source) or pulmonary parenchymal vessels + penetrating thoracic trauma: stab wound or firearm → direct vessel laceration + frequent associated lesions: pneumothorax (hemopneumothorax) + pulmonary contusion + diaphragmatic lesions + hemopericardium; non-traumatic causes (15-20 %): neoplastic: pleural metastases (lung cancer + breast + lymphomas) + pleural mesothelioma + tumor vascular invasion → bleeding into the pleural cavity + excessive anticoagulation: warfarin overdose (INR >4-5) + heparins + AOD (apixaban + rivaroxaban + dabigatran) → spontaneous hemothorax on anticoagulants → INR + anti-Xa if suspected → antidotes (vitamin K + andexanet alfa + idarucizumab) + ruptured aortic aneurysm: thoracic aortic dissection or fissuring → left hemothorax ++ → surgical or endovascular emergency + thoracic endometriosis: ectopic endometrial tissue in the pleura → cyclic recurrent hemothorax (catamenial hemothorax) → occurs in the 72h surrounding menstruation → diagnosis evoked by cyclic recurrence + laparoscopy + hormonal treatment (GnRH agonists) + VATS + pulmonary arteriovenous malformations (AVMs): arteriovenous fistulas → spontaneous rupture → often as part of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease - ENG/ACVRL1 mutations) → endovascular embolization + iatrogenic: subclavian or jugular central venipuncture → laceration of subclavian artery or vena cava → hemothorax + pleural or pulmonary biopsy + thoracic epidural catheter
- Clinical and para-clinical diagnosis: clinical picture: lateral chest pain + dyspnea (proportional to volume) + tachycardia + hypotension (if massive hemothorax → hemorrhagic shock) + decreased vesicular murmur at the base of the affected side + dullness on percussion (differentiates from pneumothorax: tympany) + in thoracic trauma: look for associated lesions - rib fractures + thoracic flap + cardiac contusion + diaphragmatic lesion + hepatic or splenic lesion if base involvement; imaging: chest X-ray (frontal + standing if possible): base opacity + effacement of costo-diaphragmatic cul-de-sac + if organized clot: dense opacity + blurred border + pleural ultrasound (FAST extended in traumatology - eFAST): gold standard in emergency → anechoic or hypoechoic collection between visceral and parietal leaflets → higher sensitivity than radiography for detecting small hemothorax + available at the patient's bed in seconds → immediate diagnostic orientation + chest CT (with injection if stable): gold standard → precise volume + localization + presence of clots + associated lesions (pulmonary contusion + pneumothorax + bone lesions + aortic lesions) → guides therapeutic decision (drainage vs VATS vs thoracotomy); pleural fluid analysis: if diagnostic doubt → pleural fluid hematocrit >50 % of blood hematocrit = hemothorax → absolute diagnostic value → LDH + proteins + cytology (if neoplastic context) + culture + BGD (if suspicion of associated empyema)
Support, drainage, and complications
| Clinical situation | Assessment and decision-making | Treatment and follow-up |
|---|---|---|
| Traumatic hemothorax — initial management ATLS - eFAST - Chest Tube - Resuscitative Thoracotomy |
Thoracic trauma with hemothorax requires a structured ATLS (Advanced Trauma Life Support - American College of Surgeons) approach and a rapid therapeutic decision depending on hemodynamic stability; ATLS approach - Primary Survey (A-B-C-D-E): A (Airway): secure the airway → intubation if GCS <8 or severe respiratory distress + B (Breathing): oxygen 15 L/min high concentration → assess ventilatory mechanics → percussion + auscultation + saturation → if massive hemothorax + respiratory distress → immediate drainage without waiting for imaging + C (Circulation): 2 large-bore IV lines (14-16G) + vascular filling (crystalloids while waiting for pellets) + group + RAI + coagulation workup + C (Disability): GCS + E (Exposure): undress + turn → look for back wounds + posterior rib fractures; eFAST (extended Focused Assessment with Sonography in Trauma): rapid ultrasound exploration in traumatology → windows: pericardial (hemopericardium) + perihepatic + perisplenic (hemoperitoneum) + bilateral pleural (hemothorax + pneumothorax) + positive FAST: pleural collection → immediate drainage decision → eFAST sensitivity for hemothorax: 92-96 % according to meta-analyses (Kirkpatrick 2004 - J Trauma) + vs radiography: 50-70 % for small hemothorax → higher eFAST in emergency; emergency biological workup: CBC + group + RAI + complete hemostasis workup (PT + APTT + fibrinogen + platelets) → if severe trauma: thromboelastography (TEG) or rotational thromboelastometry (ROTEM) → guides transfusion and correction of coagulopathy → PFC/CG ratio 1:1 in damage control resuscitation (Holcomb 2015 - JAMA + PROPPR Trial) | Thoracic drainage - technique and indications: chest tube (drain de Monod): gauge: 28-32 Fr for traumatic hemothorax (large gauge to evacuate clots) → insertion: 5th intercostal space + middle axillary line (safety triangle: anterior to posterior edge of greater dorsalis + posterior to lateral edge of greater pectoralis + superior to nipple line) → technique: local anesthesia (lidocaine 1 % + adrenaline) + 2-3 cm skin incision + finger dissection to pleura + drain insertion + connection to closed-circuit collection system (Pleur-evac) → active suction at -20 cmH₂O → hourly output monitoring; indications for hemostasis thoracotomy (resuscitation thoracotomy): massive hemothorax with persistent hemodynamic instability despite filling → formal indications: initial drainage >1,500 mL of blood + or persistent bleeding >200 mL/h × 4 consecutive hours + or >1,500 mL over 24 hours + or traumatic cardiac arrest in shock room → emergency anterolateral thoracotomy (in shock room or OR) → surgical hemostasis → resupply injured intercostal or hilar vessels; VATS (Video-Assisted Thoracoscopic Surgery): alternative to thoracotomy if hemodynamically stable → early clotted hemothorax + persistent bleeding accessible + less morbid than thoracotomy → success rate: 80-90 % for early clotted hemothorax (Meyer 1997 - Annals of Thoracic Surgery) |
| Clotted hemothorax (retained hemothorax) and fibrothorax Early VATS — intrapleural fibrinolysis — decortication |
Clotted hemothorax is the most frequent complication of undrained or insufficiently drained hemothorax - its early management is essential to avoid fibrothorax; definition and pathophysiology: clotted hemothorax (retained hemothorax): residual blood in the pleural cavity that has not fully drained → clot organized within 48-72h → within 7-14 days: fibrotic organization (pleural shell) → if not treated at this stage: fibrothorax → permanent ventilatory restriction + thoracic deformity; diagnosis of retained hemothorax: thoracic CT: precise clot localization + volume + early calcification (hyperdensity at D5-J10) + eFAST insufficient to assess clot organization → CT essential to guide decision; therapeutic strategy depending on delay and patient's condition: early stage (D1-J5): bleeding stopped + clot not organized: early VATS (ideally within 72h) → clot evacuation + complementary hemostasis + simple residual effusion <300 mL → monitoring + intrapleural fibrinolysis if VATS not available; intrapleural fibrinolysis (local thrombolysis): agents: alteplase (tPA) 10-25 mg in 50-100 mL NaCl 0.9 % → instilled into chest drain → clamped 1-4h → released → may be combined with DNase (deoxyribonuclease): dornase alfa 5 mg → dissolves neutrophil extracellular DNA (NET - neutrophil extracellular traps) → reduces viscosity + improves drainage → MIST2 protocol (Rahman 2011 - NEJM): tPA + DNase combined → reduction in radiological volume + reduction in surgeries → drainage significantly improved vs. placebo | VATS for clotted hemothorax - technique and results: VATS (minimally invasive thoracic surgery by videoscopy): 3 incisions of 5-10 mm → camera + instruments → mechanical evacuation of clots + abundant washing + complementary hemostasis + positioning of a drain at the end + duration: 45-90 min under general anesthesia + results: success rate: 85-90 % if performed within 5 days (Morales 2008 - J Trauma) → if performed late (>14 days) → fibrosis already organized → VATS less effective → decortication necessary; pleural decortication: if fibrothorax constituted (>2-4 weeks of evolution) → surgical removal of fibrous shell → release of trapped lung → restoration of ventilatory dynamics → heavy surgery → open thoracotomy or VATS if shell still sufficiently thin + functional results: improvement in FEV1 and FVC in 70-85 % of cases operated on within 3 months → poorer results if decortication delayed (>6 months); post-drainage monitoring: chest X-ray at 24h + 48h post-drainage → confirm pulmonary expansion + detect persistent air leaks + quantify residual + drain removal criteria: production <100 mL/24h + no air leak + lung re-expanded on X-ray → gradual withdrawal (deep inspiration withdrawal + Valsalva) → control X-ray at 1h post-withdrawal + control CT scan at 1-3 weeks if there is any doubt about residual + long-term monitoring: EFR (spirometry) at 3-6 months if significant hemothorax → detect residual restrictive ventilatory disorder |
| Thoracic empyema secondary to hemothorax Pleural infection — antibiotics — VATS — drainage |
Thoracic empyema (infection of the pleural cavity) is a dreaded complication of undrained or poorly drained hemothorax - blood is an excellent culture medium for bacteria; epidemiology and pathophysiology: incidence: 1-2 % after isolated chest trauma + 5-10 % if undrained clotted hemothorax → bacterial contamination: hematogenous route (bacteremia) + contiguity (open wound + associated pneumonia) + iatrogenic (chest tube left in place too long) → frequent bacteria: Staphylococcus aureus (including MRSA) + Streptococcus milleri group (Streptococcus anginosus/intermedius/constellatus) + Gram-negative bacilli (Klebsiella + Pseudomonas if immunocompromised) + anaerobes (if aspiration + dental context); diagnosis: clinical: fever + chest pain + altered general condition + lack of drainage resolution + cloudy or purulent pleural fluid (frank pus = constituted empyema) → pleural fluid analysis: pH <7.20 + glucose 1,000 IU/L + Gram + culture + pleural CBC: abundant PNN → Light's classification (exudate + criteria) → empyema stages: stage 1 (exudative): fluid liquid → drainage alone sufficient + stage 2 (fibrinopurulent): thick liquid + septa + tPA + DNase or VATS + stage 3 (organized): fibrous shell → surgical decortication | Treatment of empyema secondary to hemothorax: antibiotic therapy: start empirically as soon as diagnosed → cover Gram+ (including MRSA if risk factors) + Gram- + anaerobes → suggested regimen: piperacillin-tazobactam 4.5 g IV q6h + vancomycin if MRSA suspected (hospital setting + hemodialysis + open wound + MRSA risk factors) + duration: 3-6 weeks depending on clinical response + allow return to oral route as soon as clinically stabilized (amoxicillin-clavulanate + metronidazole if ambulatory) → adapt to antibiogram as soon as available; surgical drainage of empyema: VATS: reference method in stages 1 and 2 → evacuation of pus + debridement of partitions + lavage + positioning of a large-caliber drain + success rate: 80-90 % if performed at fibrinopurulent stage → advantage vs thoracotomy: less morbid + faster recovery → VATS Empyema Trial (Waller 2014 - Lancet): VATS from the outset superior to drainage alone to reduce hospital stay and failures; intrapleural fibrinolysis (stage 2) if VATS unavailable or patient inoperable: tPA 10 mg + DNase 5 mg (MIST2 protocol) × 3/d × 3 days → results significantly superior to placebo (Rahman 2011 - NEJM) → acceptable alternative if surgical contraindication; open decortication (thoracotomy): stage 3 with thick fibrous shell + heavy surgery → significant morbidity → reserved if VATS impossible + long-term: radiological + EFR follow-up at 3 and 6 months → most empyemas correctly treated heal without major functional sequelae if managed before fibrothorax |
| Non-traumatic spontaneous hemothorax — specific situations Neoplasm — anticoagulants — thoracic endometriosis — AVM |
Non-traumatic hemothorax requires directed etiological investigation - treatment of the cause is as important as drainage; neoplastic hemothorax: pleural metastases: lung + breast cancer + lymphoma + melanoma → bleeding from tumor neovascularization + vascular erosion → workup: thoraco-abdomino-pelvic CT + PET-CT (search for primary tumor) + pleural fluid cytology (sensitivity 60-70 % for adenocarcinomas + less sensitive for mesothelioma) + pleural biopsy (medical thoracoscopy or VATS) if cytology negative → treatment: symptomatic drainage + pleurodesis (talc slurry 4-5 g or talc insufflation under thoracoscopy) if recurrent effusion → chemo/immunotherapy depending on primary tumor; hemothorax on anticoagulants: very high INR (warfarin) or AOD overdose → drainage if symptomatic + antidotes: vitamin K 10 mg IV + PFC + PPSB (prothrombin complex concentrate) if life-threatening emergency - warfarin → andexanet alfa (Ondexxya) - apixaban + rivaroxaban → idarucizumab (Praxbind) - dabigatran → hemodialysis - dabigatran + reassessment of indication for anticoagulation + substitution with low-molecular-weight heparin if benefit maintained; thoracic endometriosis (catamenial hemothorax) : cyclic recurrent hemothorax → synchronous with menses (within 72h) → right side in 85-90 % of cases → diagnosis evoked in the face of cyclic recurrence + woman of childbearing age → confirmation: thoracoscopy (subpleural or diaphragmatic bluish nodules) + laparoscopy (pelvic endometriosis often associated) → treatment: ovarian suppression (GnRH agonists - leuprorelin + leuprolide acetate 3.75 mg IM/month × 6 months → recurrence on discontinuation frequent) + VATS: resection of diaphragmatic implants + pleurodesis → definitive treatment if desire for motherhood fulfilled | Pulmonary AVMs and Osler-Weber-Rendu disease (OWRD): pulmonary arteriovenous malformations: short-circuiting pulmonary artery → pulmonary vein → without passage through capillaries → hypoxemia (right-left shunt) + paradoxical emboli (cryptogenic stroke) + rupture → hemothorax or massive hemoptysis → context: hereditary hemorrhagic telangiectasia (HHT - Osler's disease): ENG (endoglin - chromosome 9) or ACVRL1 (ALK1 - chromosome 12) mutations → autosomal dominant transmission → recurrent epistaxis + cutaneous telangiectasias + pulmonary AVMs (50-60 % of THHs) + cerebral AVMs (15 %) + hepatic AVMs → diagnosis: spiral thoracic CT without injection + contrast bubbles on echocardiography (right-left shunt) + pulmonary arteriography (gold standard) → treatment of pulmonary AVMs: endovascular embolization (coils + vascular plugs - Amplatzer) → success rate: 90-95 % + monitoring: CT at 3-6 months + annual → re-treatment if repermeabilization + neurological monitoring + family screening (genotyping - THH centers in Canada: Hamilton + Toronto); post-procedure iatrogenic hemothorax: subclavian central approach: subclavian artery laceration (non-compressible artery + vein) → hemothorax + hemomediastinum → prevent by systematic ultrasound guidance (SCC + ACVIM + SCA recommendation since 2012) + if post-catheter subclavian hemothorax: drainage + vascular surgery if massive bleeding + preferential use of the internal jugular or femoral route in patients at high risk of bleeding |
ℹ️
Dullness to percussion and absent breath sounds ≠ pneumothorax: Both hemothorax and pneumothorax can cause respiratory distress with decreased breath sounds on one side—but percussion tells them apart: dullness in hemothorax (blood is dense) vs tympany in pneumothorax (air is less dense). In trauma, both can coexist (hemopneumothorax). eFAST allows immediate bedside differentiation, guiding appropriate decompression treatment.
Situations requiring urgent medical attention
Chest trauma, respiratory distress, hypotension, dullness to percussion, absent breath sounds → Probable massive hemothorax → Emergency eFAST → Two large-bore IVs + fluid resuscitation + blood type + antibody screen → Immediate chest tube drainage (28–32 Fr tube) → if drainage >1,500 mL initially or persistent bleeding >200 mL/h → thoracotomy for hemostasis → immediate thoracic surgery consultation.
Chest drain in place + fever + cloudy or purulent fluid + persistent chest pain → Secondary thoracic empyema → Pleural fluid collection (pH + glucose + Gram stain + culture) + blood cultures → Broad-spectrum antibiotics + thoracic surgery consultation for VATS → Do not delay management beyond 24 hours.
Recurrent right-sided hemothorax in a woman of reproductive age + synchronous menstruation → Thoracic endometriosis (catamenial hemothorax) → Drainage if symptomatic + gynecological referral + thoracic surgery for diagnostic and therapeutic thoracoscopy.
Hemothorax + low SpO2 + absence of trauma + skin telangiectasias or recurrent epistaxis Pulmonary MAV in the context of possible PAH → Spiral CT of the chest + echocardiography with bubbles + PAH center referral → Semi-urgent endovascular embolization.
Consult at Clinique Omicron
Hemothorax is a medical emergency that requires immediate hospitalization. Clinique Omicron physicians do not treat acute hemothorax at their service points, but provide post-hospital follow-up for patients who have undergone chest tube drainage or surgery for hemothorax. This follow-up includes clinical and radiological monitoring, pulmonary function testing (PFT), and coordination with thoracic surgery if a complication is suspected. For a respiratory or thoracic emergency, call 911 or go to the nearest emergency room immediately. For post-hospital follow-up, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not replace the advice of an emergency physician, pulmonologist, or thoracic surgeon. Any confirmed or suspected hemothorax constitutes a medical emergency requiring immediate hospitalization.
Omicron Clinic
Need to consult a doctor?
Treatment within 24-48 hours. In-clinic or telemedicine, anywhere in Quebec.
Insurance receipts. 7j/7. No family doctor required.