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Chest injury after either a penetrating or blunt trauma is a common presentation to the emergency department, but an unrecognized complication of traumatic hemothorax (HTX) is potentially life-threatening.6 Chest injuries occur in approximately 60% of trauma patients, with HTX or hemopneumothorax occurring in almost a third of these patients.2

The pleural layer in the chest is a serous membrane that lines the thoracic wall and lungs and can be divided into two types. The parietal layer is attached to the chest wall, diaphragm, and mediastinum. The visceral layer is an extension of the parietal layer that has been reflected back to cover the lungs. These two layers are very close together with a small amount of parietal fluid in the pleural space that separates them. Hemothorax is the presence of blood in the pleural space.

The source of blood may be trauma to the chest wall, lung parenchyma, heart, or great vessels, infection/inflammation, malignancy, coagulopathy, or congenital arteriovenous malformations.3

Blunt and penetrating trauma to the chest can result in HTX/pneumothoraces, the initial management of which includes evacuation with a tube thoracostomy (TT).5 HTX should be suspected based on mechanism of injury, physiologic parameters, and physical exam findings.2 Confirmation can be obtained with ultrasound, a chest X-ray (CXR), or chest computed tomography (CT).4

Massive hemothorax results from the rapid accumulation of more than 1500 mL of blood or one-third or more of the patient’s blood volume in the chest cavity.1 A massive hemothorax is suggested when shock is associated with the absence of breath sounds or dullness to percussion on one side of the chest.1


Massive hemothorax is initially managed by the simultaneous restoration of blood volume and decompression of the chest cavity. Thoracostomy tube placement is required to decompress the lung by draining the blood from the pleural space. The following steps are taken from the Advanced Trauma Life Support (ATLS) manual:

STEP 1. Determine the insertion site, usually at the nipple level (fifth intercostal space), just anterior to the midaxillary line on the affected side. A second chest tube may be used for a hemothorax.

STEP 2. Surgically prepare and drape the chest at the predetermined site of the tube insertion.

STEP 3. Locally anesthetize the skin and rib periosteum.

STEP 4. Make a 2- to 3-cm transverse (horizontal) incision at the predetermined site and bluntly dissect through the subcutaneous tissues, just over the top of the rib.

STEP 5. Puncture the parietal pleura with the tip of a clamp and put a gloved finger into the incision to avoid injury to other organs and to clear any adhesions, clots, and so on. Once the tube is in the proper place, remove the clamp from the tube.

STEP 6. Clamp the proximal end of the thoracostomy tube and advance it into the pleural space to the desired length. The tube should be directed posteriorly along the inside of the chest wall.

STEP 7. Look for “fogging” of the chest tube with expiration or listen for air movement.

STEP 8. Connect the end of the thoracostomy tube to an underwater-seal apparatus.

STEP 9. Suture the tube in place.

STEP 10. Apply an occlusive dressing and tape the tube to the chest.

STEP 11. Obtain a chest x-ray film.

STEP 12. Obtain arterial blood gas values and/or institute pulse oximetry monitoring as necessary.


  1. American College of Trauma Surgeons. ATLS Manual. 9th. 2013.
  2. Broderick SR. Hemothorax. Thoracic surgery clinics of NA. 2013;23:89-96. DOI: 10.1016/j.thorsurg.2012.10.003.
  3. Li PS, Tsai CL, Hu SY, Lin TC, Chang YT. Spontaneous hemothorax caused by ruptured multiple mycotic aortic aneurysms; a case report and literature. Journal of Cardiothoracic Surgery. 2017;12:1-4.
  4. Mowery NT, Gunter OL, Collier BR, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. Journal of Trauma—Injury, Infection and Critical Care. 2011;70:510-518.
  5. Scott MF, Khodaverdian JL, Ney AL, Nygaard RM. Predictors of retained hemothorax after trauma and impact on patient outcomes. European Journal of Trauma and Emergency Surgery. 2017;43:179-184.
  6. Yap D, Ng M, Chaudhury M Mbakada N. Longest delayed hemothorax reported after blunt injury. American Journal of Emergency Medicine. 2018;36:171-173.
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