You are in: eMedicine Specialties > Thoracic Surgery > Trauma HemothoraxArticle Last Updated: Oct 23, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 13
  Author: Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center Mary C Mancini is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association Editors: Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: haematothorax, haemothorax, hematothorax, chest wall injury, intrathoracic injury, trauma, chest wall hemorrhage, intrathoracic hemorrhage, penetrating trauma, blunt trauma, polytrauma, primary neoplasia, metastatic neoplasia, blood dyscrasias, anticoagulation complications, pulmonary embolism, PE, torn pleural adhesion, bullous emphysema, necrotizing infections, tuberculosis, TB, pulmonary arteriovenous fistula, hereditary hemorrhagic telangiectasia, thoracic aortic aneurysm, internal mammary artery aneurysm, intralobar sequestration, extralobar sequestration, pancreatic pseudocyst, splenic artery aneurysm, hemoperitoneum, catamenial hemothorax INTRODUCTIONSection 2 of 13
  Accumulation of blood within the chest, or hemothorax, is a relatively common problem, most often resulting from injury to intrathoracic structures or the chest wall. Hemothorax unrelated to trauma is considerably less common and can result from various causes. Prompt identification and treatment of traumatic hemothorax is an essential part of the care of the injured patient. In cases of hemothorax unrelated to trauma, a careful investigation for the underlying source must be performed while treatment is occurring. History of the ProcedureHemorrhage from or within the chest has been detailed in numerous medical writings dating back to ancient times. While lesser forms of trauma were commonly treated in the ancient physician's daily practice, major injuries, especially those to the chest, were difficult to treat and often lethal. By the 18th century, some treatment for hemothorax was available; however, controversy raged about its form. A number of surgeons, including John Hunter in 1794, advocated the creation of an intercostal incision and drainage of the hemothorax. Those of the opposing viewpoint believed that closure of chest wounds without drainage and other conservative forms of management of bloody collections in the chest were proper treatment. While Hunter's method was effective in evacuating the hemothorax, the morbidity associated with the creation of an iatrogenic pneumothorax as a result of the procedure was significant. On the other hand, the risks associated with wound closure or conservative management included the possibility that empyema with sepsis would develop or that persistent trapped lung with permanent reduction of pulmonary function would result. Observing the advantages and dangers of both forms of therapy, Guthrie, in the early 1800s, gave credence to both viewpoints. He did this by proposing the importance of early evacuation of blood through an existing chest wound and, at the same time, asserting that if bleeding from the chest persisted, the wound should be closed in the hope that existing intrathoracic pressure would halt the bleeding. If the desired effect was accomplished, he advised that the wound be reopened several days later for the evacuation of retained clotted blood or serous fluid. By the 1870s, early hemothorax evacuation by trocar and cannula or by intercostal incision was considered standard practice. Not long after this, underwater seal drainage was described by a number of different physicians. This basic technique has remained the most common form of treatment for hemothorax and other pleural fluid collections to this day.1 ProblemHemothorax refers to a collection of blood within the pleural cavity. Although some authors state that a hematocrit value of at least 50% is necessary to define a hemothorax (compared to a bloody pleural effusion), most do not agree on any specific distinction. Although the most common etiology of hemothorax is blunt or penetrating trauma, it can also result from a number of nontraumatic causes or can occur spontaneously. FrequencyQuantifying the frequency of hemothorax in the general population is difficult. A very small hemothorax can be associated with a single rib fracture and may go undetected or require no treatment. Because most major hemothoraces are related to trauma, a rough estimate of their occurrence may be gleaned from trauma statistics. Approximately 150,000 deaths occur from trauma each year. Approximately 3 times this number of individuals are permanently disabled because of trauma, and the majority of this combined group are victims of polytrauma. Chest injuries occur in approximately 60% of polytrauma cases; therefore, a rough estimate of the occurrence of hemothorax related to trauma in the United States approaches 300,000 cases per year.2 EtiologyBy far, the most common cause of hemothorax is trauma. The various etiologies follow.
PathophysiologyBleeding into the pleural space can occur with virtually any disruption of the tissues of the chest wall and pleura or the intrathoracic structures. The physiologic response to the development of a hemothorax is manifested in 2 major areas: hemodynamic and respiratory. The degree of hemodynamic response is determined by the amount and rapidity of blood loss. Normal respiratory movement may be hampered by the space-occupying effect of a large accumulation of blood within the pleural space. In trauma cases, abnormalities of ventilation and oxygenation may result, especially if associated with injuries to the chest wall. In some cases of nontraumatic origin, especially those associated with pneumothorax and a limited amount of bleeding, respiratory symptoms may predominate. Systemic physiologic response - Hemodynamic Hemodynamic changes vary depending on the amount of bleeding and the rapidity of blood loss. Blood loss of up to 750 mL in a 70-kg man should cause no significant hemodynamic change. Loss of 750-1500 mL in the same individual will cause the early symptoms of shock, ie, tachycardia, tachypnea, and a decrease in pulse pressure. Significant signs of shock with signs of poor perfusion occur with loss of blood volume of 30% or more (1500-2000 mL). Because the pleural cavity of a 70-kg man can hold 4 or more liters of blood, exsanguinating hemorrhage can occur without external evidence of blood loss. Systemic physiologic response - Respiratory Blood occupying the pleural cavity takes up space that the lung would fill in normal respiratory excursion. A large enough collection causes the patient to complain of dyspnea and may produce the clinical finding of tachypnea. The volume of blood required to produce these symptoms in a given individual varies depending on a number of factors, including organs injured, severity of injury, and underlying pulmonary and cardiac reserve. Dyspnea is a common symptom in cases in which hemothorax develops in an insidious manner, such as those secondary to metastatic disease. Blood loss in such cases is not acute as to produce a visible hemodynamic response, and dyspnea is often the predominant complaint. Physiologic resolution of the hemothorax Blood that enters the pleural cavity is exposed to the motion of the diaphragm, lungs, and other intrathoracic structures. This results in some degree of defibrination of the blood so that incomplete clotting occurs. Within several hours of cessation of bleeding, lysis of existing clots by pleural enzymes begins. Lysis of red blood cells results in a marked increase in the protein concentration of the pleural fluid and an increase in the osmotic pressure within the pleural cavity. This elevated intrapleural osmotic pressure produces an osmotic gradient between the pleural space and the surrounding tissues that favors transudation of fluid into the pleural space. In this way, a small and asymptomatic hemothorax can progress into a large and symptomatic bloody pleural effusion. Late physiologic sequelae of unresolved hemothorax Two pathologic states are associated with the later stages of hemothorax. These include empyema and fibrothorax. Empyema results from bacterial contamination of the retained hemothorax. If undetected or improperly treated, this can lead to bacteremia and septic shock. Fibrothorax results when fibrin deposition develops in an organized hemothorax and coats both the parietal and visceral pleural surfaces, trapping the lung. The lung is fixed in position by this adhesive process and is unable to fully expand. Persistent atelectasis of portions of the lung and reduced pulmonary function result from this process. ClinicalA number of the clinical findings associated with traumatic hemothorax vary from those that occur in the absence of trauma. These entities are discussed separately. Traumatic hemothorax Symptoms and physical findings associated with hemothorax in trauma vary widely depending on the amount and rapidity of bleeding, the existence and severity of underlying pulmonary disease, the nature and degree of associated injuries, and the mechanism of injury.
Clinical caveats in traumatic hemothorax Positive physical findings noted by percussion and auscultation are best appreciated in the upright patient and, even then, may be subtle. As much as 400-500 mL of blood may obliterate only the space comprising the costophrenic angle. Many trauma victims are initially examined in the supine position. In such cases, a collection of blood within the pleural space will not occupy the diaphragmatic surface, but will be distributed along the entire posterior aspect of the affected pleural space. Physical examination techniques such as percussion and auscultation may produce equivocal findings even though a substantial collection of blood is present. A hemothorax found in association with a diaphragmatic injury in either penetrating or blunt trauma may actually have its origin from an intra-abdominal source. Blood from injured abdominal organs may traverse a diaphragmatic tear and enter the thoracic cavity. In cases of hemothorax with diaphragmatic injury, the clinician should strongly consider the possibility of intra-abdominal injury.4 Nontraumatic hemothorax Symptoms and physical findings are variable, depending on the underlying pathology.
INDICATIONSSection 3 of 13
If a hemothorax is equal to or greater than the amount required to obscure the costophrenic sulcus or is found in association with a pneumothorax based on chest radiograph findings, it should be drained by tube thoracostomy. In cases of hemopneumothorax, 2 chest tubes may be preferred, with the tube draining the pneumothorax placed in a more superior and anterior position. Surgical exploration in cases of traumatic hemothorax should be performed in the following circumstances:
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 CT scan findings or opacification of one third or more of the chest on chest radiographs) 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 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. RELEVANT ANATOMYSection 4 of 13
Extrapleural In cases of trauma, disruption of the chest wall tissues with violation of the pleural membrane can cause bleeding into the pleural cavity. The most likely sources of significant or persistent bleeding from chest wall injuries are the intercostal and internal mammary arteries. In nontraumatic cases, rare disease processes within the chest wall (eg, bony exostoses) can be responsible. Intrapleural Blunt or penetrating injury involving virtually any intrathoracic structure can result in hemothorax. Massive hemothorax or exsanguinating hemorrhage may result from injury to major arterial or venous structures contained within the thorax or from the heart itself. These include the aorta and its brachiocephalic branches, the main or branch pulmonary arteries, the superior vena cava and the brachiocephalic veins, the inferior vena cava, the azygous vein, and the major pulmonary veins. Injury to the heart can produce a hemothorax if a communication exists between the pericardium and the pleural space. Injury to the pulmonary parenchyma may cause hemothorax, but it is usually self-limited because pulmonary vascular pressure is normally low. Pulmonary parenchymal injury is usually associated with pneumothorax and results in limited hemorrhage. Hemothorax resulting from metastatic malignant disease is usually from tumor implants that seed the pleural surfaces of the thorax. Diseases of the thoracic aorta and its major branches, such as dissection or aneurysm formation, account for a large percentage of specific vascular abnormalities that can cause hemothorax. Aneurysms of other intrathoracic arteries such as the internal mammary artery have been described and are possible causes of hemothorax if rupture occurs. A variety of unusual congenital pulmonary abnormalities, including intra- and extralobar sequestration, hereditary telangiectasia, and congenital arteriovenous malformations, can cause hemothorax. Hemothorax can result from pathology originating within the abdomen if bleeding from the abnormality is able to traverse the diaphragm through one of the normal hiatal openings or a congenital or acquired opening. CONTRAINDICATIONSSection 5 of 13
Needle aspiration of a hemothorax is generally not indicated for definitive treatment. In some cases of nontraumatic hemothorax, especially those that occur 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 aspiration is performed. Although the diagnostic evaluation in such cases may be performed using needle aspiration, complete evacuation of these collections often requires treatment with tube thoracostomy, similar to hemothoraces resulting from other causes. 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 and/or correction of factor deficiencies using appropriate blood products, if necessary, should be initiated prior to 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. Tube thoracostomy drainage of a hemothorax 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. WORKUPSection 6 of 13
Lab Studies
Imaging Studies
TREATMENTSection 7 of 13
Medical TherapyIntrapleural 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.5 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 observed to be fully expanded on the chest x-ray film. Drainage should be less than 100 mL in 24 hours before chest tube removal. Antibiotic coverage begun prior to surgery should be discontinued after 48 hours unless a definite reason exists for continuance. Surgical TherapyTube thoracostomy drainage Tube thoracostomy drainage is the primary mode of treatment for hemothorax. In adult patients, large-bore chest tubes, usually 36-42F, should be used to achieve adequate drainage in adults. 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 24-34F chest tube should be used, depending on the size of the child. 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. After tube thoracostomy is performed, a repeat chest radiograph should always be obtained. This helps identify chest tube position, helps determine completeness of the hemothorax evacuation, and may reveal other intrathoracic pathology previously obscured by the hemothorax. 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) operative procedure should be undertaken to evacuate the pleural space. 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.6, 7, 8, 9 Surgical exploration of the chest 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 hemothorax may be performed using VATS in selected cases. Several centers have used this modality successfully to help identify and control the source of bleeding in a number of cases. VATS evacuation of the hemothorax or retained clot can be performed safely. 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. 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, and/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. 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 and/or resection of bullous disease, resection of cavitary disease, resection of necrotic lung tissue, sequestration of arteriovenous malformations, or resection and/or repair of vascular abnormalities such as aortic aneurysms.2 Preoperative DetailsIn the majority of cases, hemothorax is identified from the initial chest x-ray film. In cases of trauma, patient assessment should be performed using the advanced trauma life support (ATLS) protocol prior to tube thoracostomy for hemothorax. Management of a traumatic hemothorax should be performed expeditiously. A tube thoracostomy tray or kit should be readily available in every hospital emergency department. Although this procedure may be performed rapidly in some circumstances, sterile technique should always be employed. The insertion site should also be infiltrated with a local anesthetic. Attention should be given to the size of the thoracostomy tube used, the location of insertion on the chest wall, and the intrathoracic position of the tube as seen on the chest radiograph. Large-bore tubes should be used and should be positioned in a dependent position within the chest for maximum drainage. 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 Indications. 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. While the luxury of a double-lumen endotracheal tube is very useful 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 2 secure large-bore intravenous lines must be established prior to surgery so that fluids and blood products can be administered rapidly if needed. A 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 prior to 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 prior to emergency exploration. Generally, a broad-spectrum cephalosporin is advisable. If thoracoabdominal injury is present and bowel injury is considered, coverage for GI 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 DetailsIn the majority of trauma cases requiring 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; although, 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 2 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 DetailsVentilator 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. 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 x-ray film. Drainage should be less than 100 mL in 24 hours before chest tube removal. Antibiotic coverage begun prior to surgery should be discontinued after 48 hours unless a definite reason exists for continuance. Follow-upAs many as 70-80% of individuals who sustain traumatic hemothorax are successfully treated by tube thoracostomy drainage and require no further therapy. A chest radiograph should be obtained immediately after removal of the chest tube. 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. Obtain at least 1 or 2 additional chest radiographs over a period of 1-2 weeks to confirm that no further intrathoracic collections or abnormalities are present. Further treatment or follow-up is determined by the nature of any other injuries. Patients undergoing surgical intervention for retained hemothorax in either an acute or late setting are monitored as any patient after VATS or thoracotomy. Generally, the chest tube is removed when drainage is 25-50 mL in 24 hours. A chest radiograph is 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 retained collections are monitored using conservative management, serial chest x-rays films should be obtained to assure resolution is occurring. 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 scan evaluation and reassessment for surgical intervention. COMPLICATIONSSection 8 of 13
OUTCOME AND PROGNOSISSection 9 of 13
At present, the general outcome for patients with traumatic hemothorax is good. Mortality associated with cases of traumatic hemothorax is directly related to the nature and severity of the injury. Morbidity is also related to these factors and to the risks associated with retained hemothorax, namely empyema and fibrothorax/trapped lung. Retained hemothorax with or without one of the aforementioned complications occurs in 10-20% of patients who sustain a traumatic hemothorax, and most of these patients require evacuation of this collection. Prognosis after the treatment of one of these complications is excellent. Short-term and long-term outcome for individuals who develop a nontraumatic hemothorax is directly related to the underlying cause of the hemothorax. FUTURE AND CONTROVERSIESSection 10 of 13
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 decreases total hospital stay when compared to more conservative management methods. The use of intrapleural instillation of fibrinolytic agents for the evacuation of hemothorax is unlikely to become routine due to the length of in-hospital time required for complete treatment and the risk of untoward effects. Ultrasonographic evaluation of the abdomen is being performed more frequently in trauma cases, especially at major trauma centers. As surgeons and emergency physicians become more adept with this diagnostic technology, a likely possibility is that ultrasonographic evaluation will also be extended above the diaphragm for evaluation of traumatic hemothorax. ACKNOWLEDGMENTSSection 11 of 13
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Jane M Eggerstedt, MD, to the development and writing of this article. MULTIMEDIASection 12 of 13
REFERENCESSection 13 of 13
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