Haemothorax in Trauma
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Direct answer
Blood accumulating in the pleural space after blunt or penetrating chest trauma presents with dullness, absent breath sounds and, when massive (over about 1500 mL), shock with flattened neck veins — and the treatment is simultaneous resuscitation with a large-bore (28–32 Fr) chest tube in the fifth intercostal space just anterior to the midaxillary line, not needle decompression, which relieves pneumothorax not haemorrhage. Immediate thoracotomy is indicated when the initial drainage exceeds 1500 mL (some protocols 1500–2000 mL) or output persists above 200 mL per hour for 2–4 hours, or with persistent transfusion requirement or haemodynamic instability despite adequate drainage. Blood that fails to drain — retained or clotted haemothorax — must be evacuated, preferably by VATS within about 3–7 days, because leaving it invites fibrothorax, empyema and a trapped lung.
What you must remember
- Sources and behaviour: systemic arterial bleeding (intercostal, internal mammary arteries, great vessels, hilum) bleeds briskly and accounts for most massive haemothorax; lung parenchymal bleeding is low-pressure and usually stops with lung re-expansion, which is why most haemothoraces are managed by tube alone.
- Signs: dullness, decreased breath sounds and reduced vocal resonance; massive haemothorax adds hypotension with flat neck veins (contrast tension pneumothorax: hypotension with distended neck veins, hyper-resonance, tracheal shift away).
- Technique: large-bore chest tube, fifth intercostal space, anterior to midaxillary line, directed posteriorly and superiorly; blunt dissection over the rib's upper border to avoid the neurovascular bundle; autotransfusion of blood from the chest tube is valuable where banked blood is scarce.
- Thoracotomy thresholds: over 1500 mL immediately on insertion, or over 200 mL per hour for 2–4 consecutive hours, or ongoing instability/transfusion need — bleeding at these rates implies a systemic arterial or hilar source that will not stop by itself.
- Retained haemothorax (over about 300–500 mL of undrained blood on CT after tube placement): early VATS evacuation within 3–7 days gives the best outcome; delaying beyond 7–10 days lets organisation begin, pushing towards decortication; antibiotics with the chest tube reduce empyema.
- Pitfalls: a clotted haemothorax can be silent on plain films (diffuse opacification) — CT is the arbiter; positioned tube placement in the fissure drains nothing; coagulopathy (dilutional, hypothermia) must be corrected in parallel; late complications are fibrothorax and empyema.
- Special situations: massive air leak with haemothorax suggests tracheobronchial injury or major laceration (bronchoscopy); associated diaphragmatic injury is easily missed on the left.
A typical exam case
A 24-year-old man is brought in after a stab wound below the left nipple. Blood pressure 88/50, pulse 120, respirations 28; the left chest is dull with absent breath sounds and neck veins are flat. Reason it through: shock plus dull hemithorax plus flat veins equals massive haemothorax — two large-bore IV lines, cross-match, and a 32 Fr chest tube now (with the trauma team activating massive transfusion protocol). The first hour drains 1200 mL and the next two hours drain 250 mL each hour. Apply the criteria: initial volume is below the 1500 mL immediate threshold, but the output exceeds 200 mL per hour for consecutive hours, and he remains tachycardic and transfusion-dependent — that combination meets the thoracotomy threshold. At thoracotomy (left posterolateral, fifth space, lung isolated) an intercostal artery laceration is suture-ligated. If instead the initial drain had been 700 mL with fading hourly outputs and a stable patient, the tube would have sufficed. But suppose day 3 shows a persistent opacified lower zone with the tube dry: CT demonstrates 400 mL of retained clot — book VATS evacuation now, within the 3–7 day window, before organisation converts a simple evacuation into a decortication.
Where students slip
The single most common mistake is treating massive haemothorax with needle decompression — that manoeuvre evacuates air, not blood, and wastes the golden minutes. The second is misreading the neck veins: tension pneumothorax and massive haemothorax both shock, but veins are distended in one and flat in the other, and the exam loves this contrast. Third, students stop at "chest tube inserted" and never state the follow-through — tracking hourly output against the 200 mL rule and CT for retained clot — yet that follow-through is precisely what the postgraduate question rewards.
Frequently asked questions
What volume of initial chest tube output mandates thoracotomy?
More than 1500 mL (about 1500–2000 mL depending on protocol) immediately on insertion, in an unstable or transfusion-requiring patient.
What rate of ongoing blood loss from a chest tube indicates surgery?
Persisting output above 200 mL per hour for 2–4 consecutive hours, or continued haemodynamic instability despite adequate drainage and transfusion.
How is retained haemothorax best managed?
Early VATS evacuation, ideally within 3–7 days, once CT confirms undrained clot; delay risks organisation, empyema and ultimately decortication.
How do tension pneumothorax and massive haemothorax differ clinically?
Both cause shock with absent breath sounds, but tension pneumothorax has hyper-resonance, distended neck veins and tracheal shift away, while massive haemothorax has dullness and flat neck veins.