The following systemwise presentation of signs and symptoms is seen in patients suffering from hemothorax:

• General appearance: Patients usually presents with anxiety and restlessness due to the profound hypovolemic shock caused by the internal bleeding in the pleural cavity. 
• Integumentary system: The skin will appear pale, cold and clammy due to the impending hypovolemic shock.
• Head and neck: The jugular veins may appear bounding and engorged due to pulmonary hypertension.
• Chest and heart: Chest pain may ensue as the blood collection irritates the pleural nerves. Hypovolemic shock may lead to tachycardia and hypotension in patients with hemothorax. Patients may present with shallow breathing due to the respiratory response of the patient to the space limiting expansion of the blood in the pleura. The region of the hemothorax in the chest may be devoid of breath sounds during auscultation and may be dull upon percussion.
• Renal: Oliguria may be an early sign of hypovolemic shock.
• Extremities: Pulses in the extremities will appear thread-like and weak due to the massive exsanguination of blood within the pleural cavity.
• Neurologic: When patients are brought in the emergency room as unconscious and obtunded, they may be suffering from late symptoms of shock and may require immediate emergency care. 

• Pain

  Shock from hemorrhage, pain, and respiratory failure follow if emergency care is not available. Also spelled haemothorax. [medical-dictionary.thefreedictionary.com]

  A 61-year-old woman presented with thigh pain and gait disturbance due to weakness in her lower right extremity. She was diagnosed with a lumbar disc herniation at L1-2 and the MIS-TLIF procedure was performed. [ncbi.nlm.nih.gov]

  [ncbi.nlm.nih.gov] pain or shortness of breath. [symptoma.com]

  On the following day mild dyspnea and chest pain developed, with pain in the right upper abdomen and vomiting. He returned to the same hospital, and erythromycin was prescribed, without benefit. [nejm.org]

• Surgical Procedure

  Such active intervention followed by surgical procedures was effective and should be considered for rare occurrences like the present case. [ncbi.nlm.nih.gov]

  Basing on CT findings, 12 patients have been treated with interventional radiology, 78 patients with surgical procedures (drainage tube, VATS, thoracotomy). [erj.ersjournals.com]

  This is a major surgical procedure, whereby an incision is made into the pleural space of the chest. If hemothorax was caused by another condition, such as a blood clotting defect, this condition will need to be treated as well. Authors: Dr. [bookinghealth.com]

• Pallor

  Entire Body System Pallor In the night following admission the patient had acute cardiovascular decompensation with worsening dyspnea, pallor and hypotension. [symptoma.com]

  In the night following admission the patient had acute cardiovascular decompensation with worsening dyspnea, pallor and hypotension. [ncbi.nlm.nih.gov]

  […] than trachea - Gunshot or other wound (hole > 2/3 tracheal diameter) +/- exit wound - Unequal breathsounds - ABG's: decreased pO2 - Air-tight dressing sealed on 3 sides - Chest tube - Surgery Massive Hemothorax - > 1500 cc blood loss in chest cavity - Pallor [fprmed.com]

  Observe carefully for pallor, blood pressure, and pulse rate, noting the early signs of shock or massive bleeding such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. [medical-dictionary.thefreedictionary.com]

• Bullet Wound

  […] occur spontaneously (e.g., malignancy) Epidemiology Demographics motor vehicle collisions (MVCs) represent the most common cause of major thoracic injury about 300,000 cases in the U.S. every year Risk factors penetrating chest trauma (e.g., stab or bullet [step2.medbullets.com]

  […] occur spontaneously ( e.g., malignancy) Epidemiology demographics motor vehicle collisions (MVCs) represent the most common cause of major thoracic injury about 300,000 cases in the U.S. every year risk factors penetrating chest trauma ( e.g., stab or bullet [medbullets.com]

• Pleural Effusion

  Presence of a pleural effusion following trauma or a rapidly enlarging pleural effusion following a pleural procedure suggests the presence of a hemothorax. Beware: there are other diseases that can mimic hemorrhagic pleural effusions or hemothorax. [pulmonologyadvisor.com]

  Pleural effusion is a clinical problem that has many causes, with hemothorax being one of them. [ncbi.nlm.nih.gov]

  Figure 2: A chest computed tomographic scan shows left-sided pleural effusion with passive atelectasis. Figure 3: Aspirated pleural effusion shows grossly bloody aspirate. [tgkdc.dergisi.org]

• Dyspnea

  When ruptured, these cysts may cause hemoptysis, dyspnea, and hydatid thorax. [ncbi.nlm.nih.gov] After thoracoscopic surgery, the dyspnea and anemia resolved. On postoperative day 5, the patient left the hospital. [symptoma.com]

  Patients with hydatid cysts typically present with cough, chest pain, dyspnea, hemoptysis, or allergic reactions. When ruptured, these cysts may cause hemoptysis, dyspnea, and hydatid thorax. [ncbi.nlm.nih.gov]

  On the following day mild dyspnea and chest pain developed, with pain in the right upper abdomen and vomiting. He returned to the same hospital, and erythromycin was prescribed, without benefit. [nejm.org]

• Pneumonia

  Rapidly progressing necrotizing pneumonia has been reported in patients with bacterially superinfected influenza pneumonia [3]. In patients with necrotizing pneumonia, affection of pulmonal artery vasculature was seen in about 40% of the cases [2]. [jmedicalcasereports.biomedcentral.com]

  A 65-year-old woman with atherosclerotic cardiovascular disease and renal failure was hospitalized for acute respiratory failure and bilateral pleural effusions associated with pneumonia (Panel A). [nejm.org]

  Influenza · Pneumonia (Viral, Bacterial, Bronchopneumonia) · Severe acute respiratory syndrome Other acute lower respiratory infections Bronchitis (Acute, Chronic) · Bronchiolitis Other diseases of upper respiratory tract Vasomotor rhinitis · Hay fever [bionity.com]

  Results revealed a large, multiloculated, right-sided pleural effusion with compression atelectasis of the right lung without underlying pneumonia. Figure 1. [consultant360.com]

  · Respiratory hypersensitivity (Allergic bronchopulmonary aspergillosis) Hamman-Rich syndrome · Idiopathic pulmonary fibrosis Obstructive or restrictive Pneumonia/ pneumonitis By pathogen Viral · Bacterial (Pneumococcal) / Atypical bacterial (Mycoplasma [wikidoc.org]

• Tachypnea

  [ncbi.nlm.nih.gov] Tachypnea She presented with tachypnea, worsening anemia, and oxygen desaturation. Hemothorax was diagnosed based on chest radiography, ultrasonography, and diagnostic thoracic puncture results. [symptoma.com]

  She presented with tachypnea, worsening anemia, and oxygen desaturation. Hemothorax was diagnosed based on chest radiography, ultrasonography, and diagnostic thoracic puncture results. [ncbi.nlm.nih.gov]

  Tachypnea Shallow rapid breathing due to respiratory distress. Tachypnea Shallow rapid breathing due to respiratory distress. [medicaljoyworks.com]

  Signs and symptoms Tachypnea Dyspnea Cyanosis Decreased or absent breath sounds on affected side Tracheal deviation to unaffected side Dull resonance on percussion Unequal chest rise Tachycardia Hypotension Pale, cool, clammy skin Possibly subcutaneous [drminkim.com]

  Patients who lose 30% of their blood volume are at risk of tachycardia (fast resting heart rate), tachypnea (abnormal or rapid breathing), and decreased pulse pressure. [docdoc.com.sg]

• Tracheal Deviation

  […] in 5th ICS, anterior axillary line [fprmed.com] Complete collapse of the lung may be followed by tracheal deviation and mediastinal shift. [symptoma.com]

  Signs and symptoms Tachypnea Dyspnea Cyanosis Decreased or absent breath sounds on affected side Tracheal deviation to unaffected side Dull resonance on percussion Unequal chest rise Tachycardia Hypotension Pale, cool, clammy skin Possibly subcutaneous [drminkim.com]

  deviation away from pneumothorax - Percussion hyperresonnance - Unilateral absence of breath sounds, hypotension - Non-radiographic diagnosis - large bore IV needle, 2nd ICS mid clavicular line, followed by chest tube in 5th ICS, anterior axillary line [fprmed.com]

  Tracheal deviation. Dull resonance on percussion. Unequal chest rise. Tachycardia. Hypotension. Pale, cool, clammy skin. Possibly subcutaneous air. Narrowing pulse pressure. [bionity.com]

  The first notable finding is tracheal deviation to the right, away from the side where the procedure was performed. This should immediately raise concern for tension physiology as the cause of the acute drop in blood pressure. [knowledgeplus.nejm.org]

• Chest Pain

  [ncbi.nlm.nih.gov] In this report, we describe a 34-year-old male patient, who presented to emergency service with sudden chest pain and dyspnea. [ncbi.nlm.nih.gov] Abstract A 58-year-old man presented with right-sided chest pain. [symptoma.com]

  Chest pain or shortness of breath Go to the emergency room or call the local emergency number (such as 911) if you have: Dizziness, fever, or a feeling of heaviness in your chest Severe chest pain Severe difficulty breathing Prevention Use safety measures [indiatoday.in]

  He was seen at another hospital, where plain chest radiographs were normal. On the following day mild dyspnea and chest pain developed, with pain in the right upper abdomen and vomiting. [nejm.org]

  The present case, as well as other previously reported cases, illustrates that sudden-onset dyspnea and chest pain in a previously healthy individual, which co-occurs with acute mediastinal widening on chest roentgenography, may be indicative of ruptured [spandidos-publications.com]

  In this paper, we share a pleural multicystic mesothelial proliferation case arrives the emergency service with sudden chest pain and dyspnea complaint that presented with hemothorax complication. [ncbi.nlm.nih.gov]

• Hypotension

  Marked blood loss produces hypotension and shock. [symptoma.com]

  […] accumulation of air in pleural space - Respiratory distress, tachycardia, distended neck veins, cyanosis, asymmetry of chest wall motion - Tracheal deviation away from pneumothorax - Percussion hyperresonnance - Unilateral absence of breath sounds, hypotension [fprmed.com]

  ] Hypotensive resuscitation has been suggested for the hemorrhagic shock patient without head trauma. [ncbi.nlm.nih.gov]

• Tachycardia

  [merckmanuals.com] Tachycardia Fluid resuscitation as needed Usually tube thoracostomy Sometimes thoracotomy Patients with signs of hypovolemia (eg, tachycardia, hypotension) are given IV crystalloid and sometimes blood transfusion (see Intravenous Fluid [symptoma.com]

  Tachycardia Due to profuse systemic blood loss, an attempt to keep the circulatory system intact. Tachycardia Due to profuse systemic blood loss, an attempt to keep the circulatory system intact. [medicaljoyworks.com]

  […] fractures pulmonary contusion pericardial tamponade tracheobronchial injury esophageal injury aortic injury pneumothorax Presentation Symptoms dyspnea pleuritic chest pain lightheadedness Physical exam vital sign abnormalities (e.g., hypotension and tachycardia [step2.medbullets.com]

  Signs and symptoms Tachypnea Dyspnea Cyanosis Decreased or absent breath sounds on affected side Tracheal deviation to unaffected side Dull resonance on percussion Unequal chest rise Tachycardia Hypotension Pale, cool, clammy skin Possibly subcutaneous [drminkim.com]

• Fracture

  Rib fractures are the commonest injury after chest trauma, which accounts for 10% of patients after trauma. A delayed massive hemothorax after simple rib fracture is rare. [ncbi.nlm.nih.gov]

  All patients had posterolateral fractures and the following fracture pattern between the 6th and 10th ribs: a series of posterolateral fractures with at least one offset or displaced fracture. [tsaco.bmj.com]

• Contusion

  Mild atelectasis is seen adjacent to the hemothoraces and likely small volume pulmonary contusion in the right lung base where a small traumatic pneumatocele is seen. [radiopaedia.org]

  Autopsy revealed a small contusion at the lower anterior part of neck, laceration on the left common carotid artery, hemothorax and a laceration over the nose with underlying fracture. [ncbi.nlm.nih.gov]

  (cause of morbidity and mortality) - paradoxical movement of flail segment - palpable crepitus of ribs - decreased air entry on affected side - ABGs : decreased pO 2, increased pCO 2 - CXR : rib fractures, lung contusion - O2 + fluid therapy + pain control [fprmed.com]

  en I also found evidence of traumatic hemothorax and pulmonary contusions. sr Ni necu jebeno morati! [glosbe.com]

• Irritability

  Hospital, Samsun, Türkiye DOI : 10.5606/tgkdc.dergisi.2022.20581 Abstract Turkish Abstract Full Text Full Text PDF Similar Articles E-mail to Author How to Cite Bronchial carcinoid tumors can present with symptoms of distal airway obstruction, local airway irritation [tgkdc.dergisi.org]

  Chest and heart: Chest pain may ensue as the blood collection irritates the pleural nerves. Hypovolemic shock may lead to tachycardia and hypotension in patients with hemothorax. [symptoma.com]

  […] thoracoscopic surgery (VATS) Second-line thoracotomy/VATS if continued bleeding or retained blood clots Complications Empyema more likely to occur if there is retained blood within the pleural cavity Fibrothorax formation of scar tissue secondary to pleural irritation [step2.medbullets.com]

  However, suction-assisted drainage of the pleural catheter itself may cause local irritation, and daily drainage of the catheter likely led to continued blood loss from the areas of poor lung expansion. [doi.org]

A good clinical history and physical examination may easily seal the diagnosis of hemothorax. However, these laboratory tests and examinations may prove to be helpful in the definitive diagnosis and the management of the hemothorax:

• Chest radiograph (X-ray): This imaging modality may reveal the exact location of the hemothorax and give the clinician the idea on the extent of the injury to the lungs.
• Computed tomography (CT-scan):  This confers a more detailed view of the lung parenchyma and the major vessels that might have been severed to cause the blood collection in the pleural space. The CT scan can accurately compute the volume exsanguinous blood in the pleural space.
• Pleural tap or thoracentesis: The laboratory analysis of the pleural fluid will confirm whether the blood in the pleura is a true hemothorax or just a bloody pleural effusion.

• Pleural Effusion

  Presence of a pleural effusion following trauma or a rapidly enlarging pleural effusion following a pleural procedure suggests the presence of a hemothorax. Beware: there are other diseases that can mimic hemorrhagic pleural effusions or hemothorax. [pulmonologyadvisor.com]

  Pleural effusion is a clinical problem that has many causes, with hemothorax being one of them. [ncbi.nlm.nih.gov]

  Figure 2: A chest computed tomographic scan shows left-sided pleural effusion with passive atelectasis. Figure 3: Aspirated pleural effusion shows grossly bloody aspirate. [tgkdc.dergisi.org]

Patients presenting in the emergency room with signs of hemothorax should be dealt with promptly. The stabilization of the cardiopulmonary status is given utmost priority followed by the prompt evacuation of the collected blood and pneumothorax in the pleural space. The application of a tube thoracostomy in patients with hemothorax remains to be the primary mode of treatment.

The use of a Video Assisted Thoracoscopic Surgery (VATS) allows the direct removal of clots in the pleura and the precise placement of the chest tubes. VATS may also be used in the direct ligation of chest bleeders to control the progression of hemothorax in some cases [6]. Even in late cases of retained clots, VATS may prove to be useful to evacuate these clots when the patient is already stabilized [7].

In cases of non-traumatic hemothorax, the open thoracotomy approach may prove to be indispensable. This procedure is most useful in the following intrathoracic surgical procedures: stapling of bullous lesions, resection of cavitary diseases and necrotic lung tissue, sequestration of arterio-venous malformation, and repair of aortic aneurysm [8].

Residual pneumothorax is treated by fibrinolysis through the chest tube using streptokinase or urokinase in saline solution [9]. The regular instillation of fibrinolytic compounds in the pleura carries a success rate of up to 92%.

In general, the outcome for traumatic hemothorax is good due to the advances in the health care delivery. Mortality rates in hemothorax varies directly to the severity of the thoracic injury and the important structures involved therein. Retained hemothorax, empyema and fibrothorax is associated with poor morbidity rating. The prompt surgical evacuation of the retained hemothorax is associated with an excellent prognosis.

Complications

The following medical conditions are known to be the common complications of hemothorax:

• Atelectasis
• Retained hemothorax
• Respiratory failure
• Fibrothorax or scarring of the pleural membrane
• Empyema
• Pneumothorax
• Hypovolemic shock
• Death

The following clinical conditions may contribute or directly cause hemothorax in patients:

• Chest trauma
• Blood dyscrasias or clotting defects
• Heart or lung surgery (iatrogenic)
• Pulmonary ischemia or infarction
• Pulmonary or pleural cancers
• Vascular tear
• Tuberculosis

In the United States, the number of hemothorax cases related to chest trauma approximates 300,000 cases per year [3]. Statistics in a trauma center have confirmed that the relative mortality rate of hemothorax among children reaches 57.1% in blunt chest trauma [4]. In penetrating chest injuries, morbidity was slated at 8.51% complicating to either atelectasis, lung infection, intrathoracic hematoma, wound infection, pneumothorax, or sepsis [5].

The pathophysiology of hemothorax is governed by two basic responses namely: the hemodynamic response, and the respiratory response. Any disruption in the integrity of the chest wall to the lung parenchyma may cause significant bleeding that can fill the pleural space. Given that the pleural cavity can hold up to 4 liters of fluids, an occult exsanguination of blood can cause hypovolemic shock to a patient without eminent bleeding from the outside. Shock can occur if blood loss amounts to more than 30% of the blood volume or approximately 1,500 ml in a 70kg man.

Early symptoms of shock includes tachypnea, tachycardia and decreased pulse pressure. While the blood collects in the pleural space, the lung parenchyma is consequently displaced and unable to expand effectively. The significant impairment in the oxygen exchange in the lungs due to the collection of blood constitutes the respiratory response phase of the hemothorax.

Traumatic hemothorax can be prevented by avoiding activities that may lead to blunt injuries to the chest wall. Seat belts must always be in place while driving. Drivers must cautiously drive motorcycles and bicycles to avoid road accidents. Patients diagnosed with tuberculosis must submit to immediate treatment and constant chest X-ray monitoring to prevent spontaneous hemothorax and pneumothorax [10].

Hemothorax is a clinical condition characterized by the presence of blood between the chest wall and the lung parenchyma (pleural space). The hemorrhage in hemothorax may originate from the lung parenchyma, the great vessels, the heart or the chest wall.

Hemothorax is usually caused by blunt trauma to chest wall but may infrequently be due to diseases conditions, iatrogenic induction or spontaneous [1]. Hemothorax needs immediate evacuation to prevent life threatening complications. To this day, the use of trocar and cannula through an incision in the chest wall to drain the blood and trapped air is still the standard practice [2].

Definition

Hemothorax is defined as a clinical condition characterized by the presence of blood in the pleural space.

Cause

Chest trauma, bleeding defects, chest surgery, pulmonary infarction, cancers and vascular problems are common causes.

Symptoms

Patients will present in anxiety and is usually restless. Signs of shock may ensue with a progressively bleeding hemothorax.

Diagnosis

A thorough clinical history and physical examination. Ancillary procedures like laboratory pleural fluid analysis and imaging techniques may also be implored.

Treatment and follow-up

Tube thoracostomy remains to be the primary mode of treatment, Open thoracotomy may also be an option, the use of VATS for hemothorax evacuation in stabilized patients may also be done, and pleural fibrinolysis may also be done to eliminate the residual pneumothorax. 

1. Tatebe S, Kanazawa H, Yamazaki Y, Aoki E, Sakurai Y. Spontaneous hemopneumothorax. Ann Thorac Surg. Oct 1996; 62(4):1011-5.
2. Rusch VW, Ginsberg RJ. Chest wall, pleura, lung and mediastinum. In: Schwartz SI, ed. Principles of Surgery. 7th Ed. New York, NY: McGraw-Hill; 1999:667-790.
3. Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex thoracic injuries. Surg Clin North Am. Aug 1996; 76(4):725-48.
4. Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Garcia VF, Bowman LM. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg. Sep 1990; 25(9):961-5; discussion 965-6.
5. Inci I, Ozcelik C, Nizam O, Eren N, Ozgen G. Penetrating chest injuries in children: a review of 94 cases. J Pediatr Surg. May 1996; 31(5):673-6.
6. Chang YT, Dai ZK, Kao EL, Chuang HY, Cheng YJ, Chou SH, et al. Early video-assisted thoracic surgery for primary spontaneous hemopneumothorax. World J Surg. Jan 2007; 31(1):19-25.
7. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. Jul 2004; 78(1):282-5; discussion 285-6.
8. Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex thoracic injuries. Surg Clin North Am. Aug 1996; 76(4):725-48.
9. Inci I, Ozçelik C, Ulkü R, Tuna A, Eren N. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax.Chest. Jul 1998; 114(1):160-5.
10. Issaivanan M, Baranwal P, Abrol S, Bajwa G, Baldauf M, Shukla M. Spontaneous hemopneumothorax in children: case report and review of literature. Pediatrics.