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Hemothorax diagnosis

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hemothorax diagnosis imaging guideline ultrasound chest radiograph CT

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https://www.ncbi.nlm.nih.gov/books/NBK538219

Hemothorax: diagnosis

Hemothorax is blood in the pleural space. It is confirmed when the pleural-fluid hematocrit is greater than 50% of the patient’s peripheral-blood hematocrit. A bloody-looking pleural effusion alone is not enough to establish the diagnosis. Murray & Nadel's Textbook of Respiratory Medicine, p. 113.

When to suspect it

Consider it in a patient with:
  • Blunt or penetrating chest trauma
  • Recent thoracic procedure, central venous catheter insertion, thoracentesis, or lung biopsy
  • Sudden pleural effusion with hypotension or falling hemoglobin
  • Less commonly, malignancy, pulmonary embolism, vascular rupture, or anticoagulation-associated bleeding

Clinical features

Findings can include:
  • Dyspnea, tachypnea, chest pain
  • Reduced chest expansion on the affected side
  • Decreased or absent breath sounds
  • Dullness to percussion
  • Tachycardia, hypotension, pallor, or shock in major bleeding
In trauma, a massive hemothorax may cause both respiratory compromise and hemorrhagic shock.

Imaging

  1. Portable chest radiograph
    • Often the first test in trauma.
    • Upright film: pleural opacity, blunting of the costophrenic angle, meniscus, or a large opacity of one hemithorax.
    • Supine trauma film can miss blood because it layers posteriorly, producing only diffuse haziness. Mulholland and Greenfield's Surgery, p. 1237.
  2. eFAST or point-of-care thoracic ultrasound
    • Fast bedside test in unstable trauma patients.
    • Shows pleural fluid as an anechoic or complex fluid collection above the diaphragm.
    • More sensitive than a supine chest radiograph for smaller collections.
  3. Contrast-enhanced chest CT
    • Most sensitive test for hemothorax.
    • Detects small or occult collections, estimates volume, identifies associated injuries, and may show active contrast extravasation. Tintinalli's Emergency Medicine, p. 1774.
  4. Diagnostic thoracentesis
    • Useful if the diagnosis is uncertain in a non-traumatic pleural effusion.
    • Send pleural fluid for hematocrit and compare with peripheral blood.

Important emergency point

Do not wait for imaging in an unstable patient with trauma and strong clinical suspicion of major intrathoracic bleeding. Resuscitation and urgent tube thoracostomy are generally required.
A massive hemothorax is commonly defined as at least 1,500 mL of blood in an adult hemithorax. Ongoing bleeding is suggested by immediate drainage of more than 1,500 mL after chest-tube placement, or persistent high-output drainage with hemodynamic instability. Tintinalli's Emergency Medicine, p. 1774.
Recent systematic reviews retrieved concern drainage strategy and conservative management rather than a change to the diagnostic approach above (PMIDs 42475926 and 39213292).
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