Last revised by Dr Joachim Feger on 13 Oct 2021

A hemothorax (plural: hemothoraces), or rarely hematothorax, literally means blood within the chest, is a term usually used to describe a pleural effusion due to accumulation of blood. If a hemothorax occurs concurrently with a pneumothorax it is then termed a hemopneumothorax

A tension hemothorax refers to hemothorax that results from massive intrathoracic bleeding, causing ipsilateral lung compression and mediastinal displacement 9.

Hemothoraces usually present with dyspnea or thoracic pain. Patients might have had trauma or malignancy in their history.

Recognized complications that can after a retained hemothorax include 7

A hemothorax is sometimes defined by pleural fluid with a hematocrit > 50% of the blood hematocrit.

It usually occurs from penetrating or blunt trauma 3 to the chest (traumatic hemothorax). 

A hemothorax can also result without any trauma and, in these situations, it is termed a spontaneous hemothorax. This can occur in the setting of 8:

Chest radiographic appearance of a large hemothorax may be similar to that of pleural effusion. It can be almost impossible to differentiate a hemothorax from other causes of pleural effusions.

May have a very high sensitivity (92%), specificity (100%) positive predictive values (100%) and negative predictive values (98%) for the detection of a hemothorax in the context of preceding trauma 2. Sonographic features characteristic, albeit nonspecific, of hemothoraces include 12;

  • homogenously echogenic effusion
    • typical of hemothoraces in the acute stage
  • plankton sign 
  • hematocrit sign 11
    • implies collection has been present for a longer period of time  
    • the cellular component may layer in the posterior costophrenic recess, creating an interface with the superficial anechoic layer

CT is useful in determining the nature of the pleural fluid in the setting of trauma by assessing the attenuation value. Blood in the pleural space typically has an attenuation of 35-70 HU 6. Pleural fluid attenuation measurement should be routine in the interpretation of chest trauma CT to distinguish simple fluid from acute blood.

In the setting of trauma, there may be other ancillary features such as pulmonary contusions and lacerations.

The exact management strategy will depend on underlying etiology. In general management options include:

  • drainage for symptomatic therapy

For a clotted hemothorax options include:

  • video-assisted thoracoscopic surgery (VATS)
  • intrapleural fibrinolytic therapy (IPFT)

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Cases and figures

  • Case 1
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  • Case 2: bilateral
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  • Case 3
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  • Case 4
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  • Case 5: gunshot injury
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  • Case 6
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  • Case 7
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  • Case 8: due to CVC tip extravasation
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  • Case 9: tension hemothorax
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