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.
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Clinical presentation
Hemothoraces usually present with dyspnea or thoracic pain. Patients typically have a history of trauma or malignancy.
Complications
Complications that can occur after a retained hemothorax include 7:
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infection
chronic fibrothorax
Pathology
A hemothorax is sometimes defined as pleural fluid with a hematocrit ≥50% of the peripheral blood hematocrit.
Etiology
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usually occurs from penetrating or blunt trauma 3 to the chest
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non-traumatic (spontaneous hemothorax) 8
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intrathoracic malignancy
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usually occurs with thoracic wall tumors
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soft-tissue tumors
sarcomas: thoracic angiosarcomas
hepatocellular carcinomas: with thoracic invasion or thoracic metastases
lung cancer: is uncommon cause even in the setting of pleural extension 8
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anticoagulant medication
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vascular rupture
rupture of coronary arteries such as RCA during an angioplasty
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thoracic arteriovenous malformations
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hematologic abnormalities: coagulopathy
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connective tissue disease
Ehlers-Danlos syndrome (EDS) type IV: in the setting of internal mammary artery rupture
congenital bony exostoses
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iatrogenic: thoracentesis, central venous catheterization and thoracotomy 13
Classification
The severity of hemothorax in an adult patient 13:
minimal: <400 mL
medium: 400 to 1000 mL
massive: >1000 mL
Radiographic features
Plain radiograph
Chest radiographic appearance of a large hemothorax may be similar to that of a pleural effusion. It can be almost impossible to differentiate a hemothorax from other causes of pleural effusions.
Ultrasound
Ultrasound has 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:
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homogenously echogenic effusion
typical of hemothoraces in the acute stage
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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
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.
Treatment and prognosis
The exact management strategy will depend on the underlying etiology. In general, drainage is performed for symptomatic therapy.
For a clotted hemothorax options include:
intrapleural fibrinolytic therapy (IPFT)
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