Massive haemothorax

A haemothorax is a collection of blood in the pleural space. It can be caused by penetrating or blunt thoracic trauma causing a laceration to the lung or intercostal vessels, mammary arteries or great vessels and heart.

In an adult, each hemithorax can hold up to 3L of blood. In a massive haemothorax, circulatory collapse can occur from exsanguination, as well as from decreased cardiac venous return from increased intrathoracic pressure. Respiratory compromise occurs from the decreased lung capacity.


Clinical signs

  • Hypotension
  • Tachycardia
  • Respiratory distress/tachypnoea
  • Hypoxia
  • Absence of lung sounds on affected side with a dull note to percussion
  • Raised JVP*
  • Trachea shifted to contralateral side*


*can be difficult to elicit these signs reliably in a trauma patient


Massive haemothorax is a CLINICAL diagnosis and definitive management in an unstable patient should not be delayed waiting for a CXR

eFAST can be utilised to rapidly confirm clinical suspicions




  • Optomise oxygenation
  • Replace blood loss
  • Perform rapid chest decompression by performing a finger or tube thoracostomy in the 5th intercostal space at the anterior axillary line.
    • If the patient spontaneously breathing, a chest drain must immediately be placed (28-32F for haemothorax)
  • Chest drain placement also allows for collection of blood which, aside from creating less mess, allows for measurement of blood loss and the collected blood can potentially be reused via a cell saver


Note that needle decompression is futile in the setting of a massive haemothorax


Indications for urgent operative thoracotomy

Major vessel bleeding should be suspected in the following situations

  • Immediate drainage of >1500ml blood
  • Drainage for >200ml/h blood over 2-4 hours


Ideally these patients should go to theatre for exploration. If the patient suffers a cardiac arrest, or is periarrest, a resuscitative thoracotomy in the ED will need to be considered.


Disposition – interhospital transfer guidelines

Massive haemothorax destination table


About this guideline

Published: February 2018

Author: Emma Batistich

Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB

Review due: 2 years