Hemothorax: Symptoms, Types, Causes and Treatment

Hemothorax, the accumulation of blood within the pleural cavity (the space between the lungs and chest wall), is a potentially life-threatening condition that demands rapid recognition and intervention. While it is most commonly associated with trauma, hemothorax can also arise spontaneously or due to various medical conditions. This article provides an in-depth look at the symptoms, types, causes, and treatment strategies for hemothorax, synthesizing evidence from published case reports, clinical trials, and practice guidelines.

Symptoms of Hemothorax

Recognizing the symptoms of hemothorax is crucial for timely diagnosis and intervention. While presentations can vary depending on the underlying cause and the amount of blood accumulated, certain signs and symptoms are commonly observed.

Symptom	Description	Commonality	Source(s)
Dyspnea	Shortness of breath	Very common	1, 2, 6
Chest Pain	Sharp or aching, often pleuritic	Common	1, 2, 4
Shock	Low BP, rapid pulse, pallor	Severe cases	1, 3, 6
Decreased Breath Sounds	On affected side	On examination	2, 4

Table 1: Key Symptoms

The Clinical Presentation

Hemothorax often presents suddenly, especially when caused by trauma or rupture of blood vessels. The most prominent symptom is dyspnea (shortness of breath), which results from the lung being compressed by accumulating blood. Patients may also report chest pain, which can be sharp, stabbing, or pleuritic (worsened by breathing or coughing) 1, 2.

A physical examination typically reveals decreased or absent breath sounds on the affected side, along with dullness to percussion due to the presence of fluid in the pleural space 2, 4.

Signs of Severe Hemothorax

When blood loss is significant, signs of shock can develop rapidly. These include:

• Low blood pressure
• Rapid heart rate
• Pallor
• Cold, clammy skin
• Confusion or decreased alertness

Such findings indicate a life-threatening emergency requiring immediate intervention 1, 3, 6.

Other Associated Features

In cases where the hemothorax is spontaneous or due to underlying disease (like cancer), symptoms may be more subtle and can include:

• Referred pain (e.g., shoulder pain from diaphragmatic irritation)
• Fatigue and malaise
• Signs of the underlying illness (e.g., symptoms of cancer, infection) 2, 7

Types of Hemothorax

Hemothorax is not a single, uniform condition—its characteristics and management vary depending on the underlying cause and clinical scenario. Understanding the different types helps guide diagnosis and treatment.

Type	Key Features	Usual Cause(s)	Source(s)
Traumatic	Follows injury or procedure	Blunt/penetrating trauma, surgery	4, 9, 12
Spontaneous	No evident trauma	Vascular, neoplastic, etc.	3, 4, 6
Retained	Clotted, not drained by tube	Complication post-drainage	8, 10, 11
Malignant	Associated with cancer	Tumor invasion/metastasis	1, 2, 5

Table 2: Types of Hemothorax

Traumatic Hemothorax

The most common type, traumatic hemothorax, results from direct injury to the chest—such as in car accidents, falls, stab wounds, or after chest surgery. It can also occur following invasive procedures like central line placement or lung biopsies 4, 9, 12.

Spontaneous Hemothorax

Spontaneous hemothorax occurs without any clear external trauma. This rare variant can result from:

• Rupture of abnormal blood vessels (e.g., in connective tissue disorders)
• Underlying lung or pleural tumors
• Coagulopathy (bleeding disorders)
• Rib fractures after severe coughing 3, 6, 7

Retained (Clotted) Hemothorax

A retained hemothorax refers to situations where blood within the pleural cavity clots and cannot be evacuated by initial drainage. This may occur after trauma or surgery and can lead to infection or fibrosis if not managed properly 8, 10, 11.

Malignant Hemothorax

In rare cases, malignant hemothorax develops due to direct invasion or metastasis of cancers (most notably hepatocellular carcinoma, mesothelioma, or metastatic tumors) into the chest wall or pleura, causing bleeding 1, 2, 5.

Causes of Hemothorax

Understanding the causes of hemothorax is critical for both prevention and management. While trauma is the most familiar cause, clinicians must remain vigilant for less common origins.

Cause	Mechanism/Example	Typical Presentation	Source(s)
Chest Trauma	Rib fracture, penetrating wound	Sudden, post-injury	4, 6, 9, 12
Iatrogenic	Medical procedures (biopsy, etc)	After intervention	4, 9
Vascular Rupture	Aortic dissection, AVM, aneurysm	Spontaneous/severe	3, 4
Tumors	Invasion/rupture (e.g., HCC)	Gradual, sometimes acute	1, 2, 5, 7
Coagulopathy	Anticoagulant use, clotting disorder	Spontaneous or minor trauma	3, 4, 9
Rib Lesions	Exostosis, osteochondroma	Spontaneous, recurrent	7
Severe Cough	Cough-induced rib fracture	After bouts of coughing	6

Table 3: Common Causes of Hemothorax

Traumatic and Iatrogenic Causes

• Blunt or penetrating trauma is by far the most frequent reason for hemothorax, often seen in emergency settings 4, 6, 9, 12.
• Iatrogenic causes include complications from central venous catheter insertion, thoracentesis, or surgical interventions 4, 9.

Vascular Causes

• Spontaneous vascular rupture can occur in patients with aortic dissection, arteriovenous malformations (AVMs), or aneurysms. These are rare but often catastrophic events 3, 4.

Tumor-Related Causes

• Malignant tumors such as hepatocellular carcinoma (HCC) can invade the chest, pleura, or diaphragm, leading to spontaneous bleeding. Tumors like hemangiopericytoma or costal exostosis can also erode into vessels or adjacent structures, triggering hemothorax 1, 2, 5, 7.

Other Causes

• Coagulopathies (clotting disorders or anticoagulant medications) can predispose to bleeding into the pleural space, sometimes after only minor trauma 3, 4, 9.
• Rib bone lesions, such as exostosis (osteochondroma), may cause mechanical injury to the diaphragm or pleura 7.
• Severe or chronic coughing can, in rare cases, fracture ribs and tear intercostal arteries, as seen in some case reports 6.

Treatment of Hemothorax

The management of hemothorax is dictated by the underlying cause, severity, and the patient’s clinical status. Prompt intervention is essential to prevent life-threatening complications.

Treatment	Indication	Outcome/Consideration	Source(s)
Tube Thoracostomy	Most cases (traumatic, moderate-severe)	Standard first-line	9, 11, 12
Pigtail Catheter	Stable, small-moderate hemothorax	Equal efficacy, better tolerance	11, 12
Surgical Intervention	Ongoing bleed, massive/clotted cases	Thoracoscopy, thoracotomy	9, 11
Lytic Therapy	Retained (clotted) hemothorax	High success rates	8, 10
Embolization	Active arterial bleeding (e.g., tumor)	For select cases	1, 2
Pleurodesis	Malignant or recurrent cases	Alternative management	2

Table 4: Main Treatment Approaches

Initial Stabilization

• Airway, breathing, and circulation (ABCs) are addressed first, with supplemental oxygen and IV fluids or blood products as needed for shock.
• Imaging (chest X-ray, ultrasound, or CT scan) confirms the diagnosis and quantifies blood accumulation 2, 9.

Drainage Procedures

• Tube thoracostomy (chest tube insertion) remains the gold standard for most moderate to large hemothoraces. It allows evacuation of blood, lung re-expansion, and monitoring of ongoing blood loss 9, 11.
• Pigtail catheters (small-bore 14-Fr tubes) are now shown to be as effective as traditional large-bore chest tubes for many patients, with better patient-reported comfort and similar complication rates 11, 12.

Advanced Interventions

• Surgical intervention (video-assisted thoracoscopic surgery [VATS] or open thoracotomy) is required in cases of:

  • Massive hemothorax (>1500 mL blood loss)
  • Persistent bleeding (>200 mL/hour)
  • Retained/clotted hemothorax not responsive to drainage or lytic therapy 9, 11

• Intrapleural lytic therapy using agents like streptokinase or urokinase can be considered for retained clotted hemothorax, with high rates of success in avoiding surgery 8, 10.

• Transcatheter arterial embolization (TAE) is a specialized procedure used for active arterial bleeding, especially in tumor-related cases. It can rapidly control hemorrhage, but outcomes may depend on the underlying disease 1, 2.

Special and Supportive Therapies

• Antibiotic prophylaxis is recommended for trauma patients undergoing chest tube insertion to reduce infectious complications 9.
• Pleurodesis (chemical or mechanical) may be used in malignant or recurrent hemothorax to prevent fluid reaccumulation 2.
• Supportive care (pain management, respiratory support, blood transfusion) is essential throughout recovery.

Conclusion

Hemothorax is a complex clinical emergency with diverse causes, presentations, and management strategies. Early recognition and tailored treatment are vital for improving patient outcomes.

Key Takeaways:

• Hemothorax most often presents with dyspnea, chest pain, and decreased breath sounds, but can progress to shock in severe cases.
• Types include traumatic, spontaneous, retained (clotted), and malignant hemothorax, each with distinct etiologies and management implications.
• Causes range from trauma and medical procedures to vascular rupture, tumors, bone lesions, and severe coughing.
• Treatment is guided by severity and type—ranging from chest tube or pigtail catheter drainage, lytic therapy for clotted blood, surgical intervention for massive or retained hemothorax, to specialized approaches like embolization and pleurodesis in select cases.

Timely diagnosis and individualized management can be lifesaving, highlighting the importance of a multidisciplinary approach for this potentially fatal condition.