Massive haemothorax is defined as drainage of >1500 mL of blood on placement of an intercostal catheter or continuing drainage of blood (200 mL/hr for 2-4 hours). Other factors to consider are the haemodynamic instability and need for persistent blood transfusion. It is important to ascertain that the chest cavity is completely evacuated of blood.
Patients with a massive haemothorax are generally unstable – this should be detected clinically (as part of the primary survey)
Smaller haemothoraces may have subtle clinical findings
Please note – the source of bleeding could also be in the abdomen, if there is associated diaphragmatic hernia.
A small haemothorax might not be evident on CXR (especially if supine) – look for subtle increase opacification over the affected hemi-thorax.
Around 350-400ml of blood needs to be present before blunting of the costophrenic angle becomes evident on an erect CXR.
USS (eFAST) has a higher sensitivity than CXR for detecting smaller haemothoraces (92% sensitivity in one study).1
CT is the definitive imaging study for detecting a haemothorax
As there is a risk that an undrained haemothorax can lead to retained clot and then empyema, haemothoraces that are estimate to be 300-500ml or greater should be considered for drainage by insertion of a tube thoracostomy.
Controversy exists over the best size drain to insert – moderate sized drains (28-32F) have been shown to be as effective as large drains (36-40F) in managing traumatic haemothorax.3 Some studies have even shown that smaller (14F) pigtail drains might be as efficacious as larger drains4 however more research is needed.5
At present, it is still recommended that a larger bore drain (ie: 28-32 F) be inserted for patient with traumatic haemothoraces.
Massive haemothorax may potentially need thoracotomy to control bleeding. Please view the referral guidelines as below.
Blunt neck (cerebrovascular) trauma
First published: February 2018 (Author: Emma Batistich)
Updated April 2021 (Sue Johnson)
Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB, NRHL, St John
Review due: 2 years