Management of Hemothorax Tube thoracostomy drainage is the primary mode of treatment for hemothorax. In adult patients, large-bore chest tubes, usually 36-42F, should be used to achieve adequate drainage in adults. most patients with hemothorax should be treated with tube thoracostomy which allows continuous quantification of bleeding * if the bleeding emanates from the laceration of the pleura, apposition of the two pleural surfaces is likely to stop bleeding If pleural hemorrhage exceeds 200 ml/h, consideration should be given to thoracoscopy or thoracotomy

Thoracostomy – a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air or fluid or pus from the intrathoracic space Thoracoscopy – medical procedure involving internal inspection of the pleural cavity. With pleurodesis, can appose pleura or stick pleurae together, eliminating the pleural space and preventing fluid accumulation Thoracotomy –an incision into the pleural space of the chest – procedure of choice for surgical exploration of the chest when massive hemothorax or persistent bleeding is present. At the time of surgical exploration, the source of bleeding is controlled and the hemothorax is evacuated.

Medical Therapy: Intrapleural instillation of fibrinolytic agents - for evacuation of residual hemothorax in cases in which initial tube thoracostomy drainage is inadequate. - proposed dose is 250,000 IU of streptokinase or 100,000 IU of urokinase in 100 mL of sterile saline.

Hemothorax-Blunt Trauma Algorithm Minimal (500 ml or less) – Observe No progression – Repeat film – Clearing – No treatment Increasing hemothorax – Chest tube » Bleeding stops. Clearing and no further treatment » Continued bleeding exceeding 1000 mL requires thoracotomy Moderate ( mL) – Chest tube Bleeding stops – Clearing and no further treatment – Persistent hemothorax requires thoracotomy Continued bleeding requires thoracotomy

Major (more than 1000 mL) – Opacified hemothorax – Over 1000 mL immediate loss – Unstable patient not responding to volume – Continued loss > 100 mL/hr after hours - thoracotomy or loss > 200 mL/hr after hours] - thoracotomy Findings that require arteriography regardless of state or volume of hemothorax. – Widened mediastinum – First rib fracture with pulse deficit, neurological deficit, or expanding hematoma.