Chest Tube Placement for Possible Hemothorax

A hemothorax is a collection of blood within the pleural cavity. Blood can accumulate within this space as a sequelae of chest trauma (penetrating or blunt), iatrogenic injury (e.g., vascular access injuries), or spontaneously (e.g., due to malignancy). To treat the condition, a chest tube is inserted into the thoracic cavity on the affected side of the body (“tube thoracostomy”). In addition to evacuating blood from the pleural cavity, a chest tube can also be used to treat pneumothorax (air in the pleural space) and pleural effusion (e.g., empyema or chylothorax), and to insert medications into the pleural space. Depending on the specific pathology, a tube or catheter may be utilized.

Pleural diseases; hemorrhage; chest tubes; chest tube placement; thoracic injuries.

A hemothorax is a collection of fluid within the pleural space with hematocrit >50% of peripheral blood.^1, 2 The chest presents a large potential space for bleeding, which may arise from diaphragmatic, mediastinal, pulmonary, pleural, chest wall, and abdominal injuries. In acute presentations of hemothorax, there are significant physiologic consequences.³ Cardiac output decreases as a result of reduced preload secondary to hypovolemia and left ventricular dysfunction. Blood in the pleural space decreases the functional vital capacity of the lung by creating alveolar hypoventilation, V/Q mismatch, and anatomic shunting. In massive hemothoraces (defined as >1500 mL of blood evacuated after closed tube thoracostomy, >200 mL of drainage per hour, or need for continuous transfusion to maintain hemodynamic stability), these cardiopulmonary mechanisms may result in tension physiology, resulting in hemodynamic instability, cardiovascular collapse, and eventually death if not managed correctly.⁴ The volume of hemothorax required for manifestation of tension physiology, however, depends on individual patient characteristics.^5, 6

The three main etiologies of hemothorax include traumatic, iatrogenic, and spontaneous.⁷ Traumatic hemothoraces result from blunt or penetrating injury to the chest. Iatrogenic injury may result from cardiac surgery, placement of central venous catheters, or other cardiothoracic procedures. Spontaneous hemothoraces are commonly caused by rupture of pleural adhesions, primary neoplasms, and pleural metastases.¹

There are limited data describing the relative frequencies of each etiology, but traumatic hemothoraces are by far the most common.¹ A study in adults estimated the incidence of each type of hemothorax: blunt trauma 73.3%, iatrogenic 25.0%, and spontaneous 1.7%.⁸ An estimated 300,000 hemothoraces occur annually in the United States,⁹ resulting in 16,000–30,000 deaths per year.^7, 10 Chest injury occurs in approximately 60% of polytrauma patients; thus, clinicians should suspect hemothorax in any patient arriving at the emergency department following blunt or penetrating chest trauma.⁵

The identification of hemothoraces and decision to intervene relies upon clinical presentation and radiologic evidence. Chest radiography (CXR) remains the initial modality for rapid evaluation of thoracic injury. A main advantage of CXR is that it can be performed quickly and portably; however, there are other important considerations and limitations. Patients should be in an upright position during imaging, as supine positioning distributes blood across the height of the chest and may inadvertently conceal approximately 1000 mL of blood.⁷ There must be at least 300 mL of blood to blunt the costophrenic angle and detect the hemothorax on CXR. Finally, estimation of hemothorax volume with CXR depends on patient positioning and clinician experience. Computed tomography (CT) scan of the chest provides greater resolution and identification of smaller fluid collections, as well as more accurate volume calculation.⁵ Ultrasonography performed and interpreted by clinicians at the bedside (in a similar manner to focused assessment with sonography for trauma, or FAST exam) has also been shown to be effective in identifying hemothorax and generally provides results more quickly than CT.^5, 11

Tube thoracostomy is the first-line treatment for most hemothoraces.^5, 9, 12 Once a hemothorax >300 mL has been identified on imaging, or if there is a high index of suspicion from physical exam findings (such as tracheal deviation, absent breath sounds, or serious penetrating injuries with associated hemodynamic instability), chest tube placement is used to evacuate the blood from the chest and restore normal cardiopulmonary physiology.^5, 7 Prompt evacuation of the hemothorax with proper tube placement prevents coagulation and adhesion to the lung and pleura (fibrothorax)¹ and is associated with decreased risk of empyema, pneumonia, fibrothorax and retained hemothorax.^2, 13, 14

A thorough history from the patient, witnesses, and EMS helps to stratify the risk of intrathoracic injury. Important history components include chest pain, dyspnea, mechanism of injury (fall, direction, and speed), drug/alcohol use, comorbidities, surgical history, and anticoagulation/antiplatelet therapies. Motor vehicle crash >35 mph, fall from >15 feet, pedestrian ejection >10 feet, and trauma with depressed level of consciousness are mechanisms predictive of significant thoracic injury.^4, 15

A complete physical examination of the patient is also crucial. Clinical findings of hemothorax are broad and may overlap with signs and symptoms of pneumothorax. Often, the degree of symptomatology is dependent upon the volume of blood within the chest. Manifestations of hemothorax include respiratory distress, tachypnea, decreased or absent breath sounds, dullness to chest wall percussion, chest wall asymmetry, tracheal deviation, hypoxia, narrow pulse pressure, and hypotension. Clinicians should inspect the chest wall for abrasions, penetrating injury, paradoxical motion ("flail chest”), ecchymosis, chest wall deformities, crepitus, and point tenderness. Distended neck veins are concerning for hemothorax, pneumothorax, and/or pericardial tamponade but may be absent in the setting of hypovolemia or hemorrhagic shock. Increased respiratory rate, effort, and use of accessory muscles may be signs of impending respiratory failure.⁴

The following physical findings should prompt a high clinical suspicion for hemothorax:

Table 1. Physical exam findings and potential injuries in patients with thoracoabdominal trauma. Adapted from Gomez 2020.

While CXR is traditionally used for initial evaluation in the emergency department, it has limitations, including the need for upright patient positioning for optimal results, poor detection of small hemothoraces (<300-500 mL), limited quantification of hemothorax size, and limited ability to differentiate between hemothorax and other thoracic pathologies.^5, 9 Cross-sectional imaging of the chest with a CT scan may help discern between pulmonary contusion, pneumonia, pleural effusion, retained hemothorax, and empyema.⁹ 

Bedside ultrasound has emerged as an increasingly popular method for identifying hemothorax. Multiple studies have shown that ultrasound can detect hemothoraces with high sensitivity (67–90%) and specificity (99%), as well as accurately quantify their size.^11, 15, 16 Ultrasound is more sensitive than CXR, but less sensitive than chest CT and may miss certain mediastinal injuries.^16, 17 Additionally, its accuracy is limited by the experience of the operator.¹⁶

Hemothorax is most commonly a complication of blunt or penetrating thoracic trauma.^{1, 4, 5, 7} Hemothorax, hemopneumothorax, and pneumothorax are the most common complications of either penetrating or blunt thoracic trauma, with a frequency ranging from 10–37%.⁷ Motor vehicle crashes cause 70% of blunt thoracic trauma,^10, 18 and overall mortality from hemothorax ranges from  9.4–42.3%.^7, 19 Gunshot wounds and stab injuries are the primary etiologies of penetrating thoracic trauma and have a much greater mortality with up to more than 90% of patients dying in the field.²⁰ 

Rib fractures are a major risk factor associated with the acute and delayed development of hemothorax.⁷ Patients with hemothoraces (among other complications, like flail chest) associated with five or more rib fractures are 2.5 times more likely to die than those with fewer than five rib fractures.²¹ Despite this association, rib fixation remains incompletely studied and controversial.⁷

Table 2. The relationships between the number of rib fractures and hemothorax in patients with thoracic trauma from Frank Cheau-Feng Lin et al.²²

There are four general options for management of hemothorax: expectant monitoring, tube thoracostomy, video-assisted thoracic surgery (VATS), and thoracotomy.⁷ Hemothoraces disrupt the normal functions of the cardiopulmonary system: ventilation, gas exchange, and perfusion. The goal of treatment is to promptly decompress the chest by evacuating blood from the pleural space to restore normal cardiopulmonary physiology. Furthermore, expeditious and complete evacuation of hemothoraces reduces the risk of complications associated with retained hemothorax.

International practice management guidelines suggest that all hemothoraces, regardless of size, should be considered for tube thoracostomy, which is the first-line treatment for drainage.^5,23 Western Trauma Guidelines recommend in patients with hemodynamic or physiological abnormality attributable to a hemothorax, clinicians should perform finger thoracostomy and standard chest decompression with 28 Fr chest tube.¹² Pleural lavage with lavage volume of at least 1000 mL may also be considered, especially in patients with penetrating injuries as it may decrease the need for secondary intervention (e.g., VATS) and decrease hospital length of stay.^24,25 Hemodynamically and physiologically stable patients with hemothorax estimated to be >300–500 mL should undergo tube thoracostomy with 14 Fr to 28 Fr chest tubes and pleural lavage.¹²

Expectant monitoring with repeat imaging (CXR) within 24 hours and careful observation may be performed in patients with hemothoraces estimated to be <300–500 mL.^12,26–28 At our institution, repeat imaging is typically performed after 6 hours. Serial imaging and careful observation should monitor for not only changes in hemothorax volume, but also changes in clinical presentation. Clinical status should be the principal factor in decision-making. These small hemothoraces typically resorb over several weeks.³ 

After placement of the chest tube, the effectiveness of drainage should be evaluated with repeat CXR. Persistent CXR abnormality after tube thoracostomy warrants additional CT imaging,²³ and if there is a retained hemothorax shown on CT to be >300–500 mL, VATS should be done within 72 hours.¹² It is important to note that VATS, not a second chest tube, is the recommended treatment for persistent retained hemothorax.^12,23 Inadequate drainage that develops after 72 hours may also be treated with thrombolytics in appropriate patients.¹²

While approximately 85% of hemothoraces can be managed with a closed tube thoracostomy, open decompression with thoracotomy is sometimes required for massive hemothorax.²⁹ Criteria for massive hemothorax prompting thoracotomy are traditionally defined as an initial output of more than 1,500 mL of blood following tube thoracostomy, drainage of more than 200 mL per hour for 4 hours, or the requirement of persistent blood transfusion to maintain hemodynamic stability.^1,5,6,20,23 However, it is critical to note that rather than absolute volume of initial or ongoing chest-tube output, the primary indicator for surgical intervention must be the physiologic parameters and overall condition of the patient.²³

Up to 25% of patients who undergo tube thoracostomy develop infectious complications,¹³ and the development of empyema or other infectious complications is multifactorial. Risk factors for infectious complications include mechanism of injury (blunt injury vs. direct contamination by penetrating injury), patient comorbidities (e.g., immunocompromised), operative setting (e.g., emergency department vs. ICU vs. operating room), and other patient injuries.²⁹ There is limited evidence available, and the role of prophylactic antibiotics in tube thoracostomy is controversial.²⁹

There are some patients who should not initially undergo tube thoracostomy for hemothorax. Extensively destroyed chest wall/lung or impaled objects may warrant immediate operative intervention. Additionally, penetrating wounds with trajectories towards the heart or great vessels or suspicious of a great vessel injury demand surgical exploration of the chest.⁶

This video depicts a case of a 57-year-old female without significant medical history presenting to the Emergency Department complaining of pain with inspiration and right rib pain, four days after slipping on ice and falling on her right side while trying to cross the street. CXR performed in the trauma bay was concerning for right hemothorax, and the team elected to perform tube thoracostomy.

Hemothorax is a common consequence of thoracic trauma.⁵ Upright CXR is traditionally used for initial identification of hemothoraces but is limited by patient positioning and sensitivity. CT is the most sensitive, and use of ultrasonography is increasingly common. Ultrasound and CT allow for size estimation of the hemothorax, while CXR does not.^1,5,11 Patient physiology and hemodynamics must remain at the forefront of clinical decision-making in the management of hemothorax, rather than strict adherence to quantitative guidelines on estimated hemothorax size or chest drainage.^5,6,23,27,28 Though small hemothoraces (<300–500 mL) may be managed with expectant monitoring,¹² 85% are managed successfully with tube thoracostomy. The remaining 10–15% are massive hemothoraces that require surgical intervention.^23,29 

The use of VATS and its relationship to tube thoracostomy in the management of hemothorax is an area of active investigation.²³ VATS is the first-line treatment for retained hemothorax after chest tube placement,^12,23 and several studies have indicated it may be safe to proceed directly to VATS for identification of intrathoracic injuries before chest tube placement in stable patients.^30,31 It is unknown, however, if use of VATS leads to shorter hospitalizations or fewer complications than tube thoracostomy alone, and future work is needed to more clearly identify the role of VATS in the treatment of acute and retained hemothorax.²³

Despite the high prevalence of chest tube placement, clinical outcomes data for the procedure are heterogenous and limited, relying heavily on retrospective studies at individual centers.⁶ Future work investigating unanswered questions surrounding tube thoracostomy for hemothorax and retained hemothorax, including fibrinolytics, when to “watch and wait,” use of VATS, and ideal antibiotic prophylaxis should be conducted using prospective, multicenter, and randomized trials.^6,23,29

• Chest Tube Insertion Tray - Bioseal32.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

We would like to thank our patients, trainees, and faculty at the University of Chicago Medical Center.