The Journal of Cardiothoracic Trauma

: 2021  |  Volume : 6  |  Issue : 1  |  Page : 1--3

Usual and unusual intrathoracic hemorrhage

Kenneth L Mattox 
 Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Chief of Staff and Surgeon-in-Chief Ben Taub Hospital, Houston, Texas, USA

Correspondence Address:
Kenneth L Mattox
Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Chief of Staff and Surgeon-in-Chief Ben Taub Hospital, Houston, Texas

How to cite this article:
Mattox KL. Usual and unusual intrathoracic hemorrhage.J Cardiothorac Trauma 2021;6:1-3

How to cite this URL:
Mattox KL. Usual and unusual intrathoracic hemorrhage. J Cardiothorac Trauma [serial online] 2021 [cited 2022 Jan 19 ];6:1-3
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Full Text

Outcomes of trauma to and in the chest have been the subject of many published articles, along with descriptions of the various organs that can be injured. Etiologies of chest trauma include blast, crush, blunt force, penetrating, and iatrogenic injuries. Fortunately, most chest trauma can be managed by rather simple techniques, including tube thoracostomy, rib fixation, direct suture repair, or observation. Among all injuries to the chest, 15% or less will ever require a formal (or even an emergency) operation.

Indications for formal thoracotomy include:

Significant and continuing hemorrhageMassive air leakPericardial tamponadeDocumented injury to esophagusDocumented injury to major bronchus or tracheaLoss of chest wall substanceSome cases of flail chestCertain life-threatening warfare agents (such as unexploded grenade)Resuscitative thoracotomy in the emergency center and other locations.

This article focuses on intrathoracic hemorrhage, either intrapleural or intrapericardial.

 Tube and Catheter Thoracostomy

Perhaps the most frequently performed operation in the world is the emergency insertion of a drainage tube into the pleural space, commonly called tube thoracostomy. Historically, this has been a 36 French tube connected to either a commercial collection device or a series of “chest bottles” to create an underwater seal, a mechanism to set the suction negative pressure, and a one-way valve. In recent years, the use of various catheters, particularly smaller “pigtail” catheters have been reported. These catheters then serve as a monitor of conditions inside the pleural cavities to include:

Rate of bleedingVolume of hemorrhage over timeColor of the hemorrhaged bloodPerceived “temperature” of the blood egressing the chestPresence of an air leakVolume of any air leak.

It is beyond the scope of this editorial to address the techniques and management of chest tubes and catheters, a subject extensively covered in textbooks, courses, and written guidelines. The major purpose in addressing chest tubes is to assure an understanding of these tubes as monitors and adjuncts in evaluating and treating posttraumatic thoracic hemorrhage.

 Sites of Intrathoracic Hemorrhage

Virtually, every organ and the tissue inside the chest and composing the chest wall have the capability to bleed following trauma, with the risks and continued hemorrhage dependent on many factors, including the answers to the following questions:

Is the patient taking any anticoagulants?Has the patient developed any form of coagulopathy?Is hemorrhage arterial or venous?What is the rate and volume per unit time of any hemorrhage?Is hemorrhage from a major vascular structure, the lung, the heart, or the chest wall?

In most penetrating injuries, most bleeding from the lung is self-limiting, as the lung is rich in tissue thromboplastin. On the other hand, bleeding from the great veins, major arteries, and the heart tends NOT to diminish, and suspected or documented hemorrhage from these sites requires almost immediate thoracotomy through an appropriate incision. More than 12 incisions for traumatic chest injury have been described.

 Evaluation of Hemorrhage Via Tube And Catheter Thoracostomy

Excluding emergency resuscitative thoracotomy for patients with acute pericardial tamponade, patient management decisions, particularly the need for thoracotomy, are tremendously influenced by the potential monitoring functions cited in this article.

For more than 30 years, two-volume values have prompted trauma surgeons to perform lateral or posterolateral thoracotomies. Neither of these two values has been scientifically evaluated, but they seem so intuitively correct they have been accepted worldwide and often cited in the literature. If the initial single effluent from a hemothorax be 1500 ml or more, immediate OR thoracotomy has been performed. The second value, sustained volume of 200 ml effluent per hour during and over the subsequent 10 h after tube thoracostomy, historically prompts performing a thoracotomy. Of course, if the bleeding rate progressively increases, then thoracotomy is indicated.

Another assessment relative to bleeding from a hemithorax has been determining if bleeding is venous or arterial. This is usually accomplished by the color of the blood, with arterial bleeding being more red if the patient is oxygenating sufficiently. Venous bleeding seems to spontaneously stop and not require a thoracotomy for control.

An assessment taught me by an intensive care unit (ICU) nurse for patients who seem to have progressive or sustained rate of hemorrhage is to evaluate the blood temperature by grasping the chest tube. If the tube is hot, head for the operating room for a thoracotomy. The rate of bleeding is so rapid that the blood in the tube has not had the opportunity to reach room temperature.

During the past 30 years, interest in recycling shed intrathoracic blood through autotransfusion has had intermittent focus. A variety of devices that can be used in the emergency center, operating room, and even the ICU have been devised and described in both textbooks and articles. Some devices even wash the blood, concentrate the red cells, and package them to be administered like blood from the hospital blood bank.

 Retained Clotted Hemothorax

For a variety of reasons, blood in the pleural space may have sufficiently clotted at the time of the insertion of even a 36 French chest tube so that the clot is retained and so noted in the first postchest tube chest X-ray. Left unremoved, various complications can occur, including trapped lung and fibrothorax, often requiring complex decortication. For this reason, very early removal of the retained clotted hemothorax should be accomplished. If performed within a day or two from discovery, evacuation can often be accomplished through thoracoscopy. Do not attempt the removal of a retained clotted hemothorax by inserting a larger or additional chest tube. Furthermore, the use of various fibrinolytic agents is discouraged. Both tactics simply do not produce satisfactory results in removing the clot and preventing the complications

 Hemorrhage from Thoracic Great Vessels

The thoracic great vessels include both arterial and venous structures of large size. The pulmonary artery and veins, the aorta and its branches, the innominate veins and arteries, the vena cava, and the azygos veins would all be considered great vessels and can bleed at a very rapid rate. Patients presenting in extremis and not surviving emergency room urgent resuscitative thoracotomy often have an injury to one or more of these great vessels. However, survivors from injury to every named great vessel have been reported. Trauma centers are urged to develop protocols in keeping with their resources and capabilities for such injuries.

 Pericardial Tamponade

Pericardial tamponade is the ultimate compartment syndrome, but within the closed space containing the heart and connecting vessels. Posttraumatic cardiac arrest at the scene and during urgent transport to a trauma center is often secondary to the heart being unable to fill during diastole. One value of EC ultrasound is immediate evaluation for blood in the pericardial space. One simple physical examination tactic in patients with signs or symptoms of pericardial tamponade is to feel and calibrate the strength of a major artery at the wrist, neck, or femoral area, and then ask the patient to Valsalva (strain very hard while taking a deep sustained breath). Should the pulse go away, because this maneuver increases the intrathoracic pressure, adding to the compartment syndrome in the pericardial space, this suggests the presence of pericardial tamponade. Should the pulse indeed go away, tell the patient to breath, allowing for the right heart filling. Prepare for an immediate thoracotomy (usually with a left 4th interspace anterolateral thoracotomy), performed by surgeons, either in the emergency center or in the operating room. Do not delay the thoracotomy.

 Obscure Bleeding Sources

All etiologies can produce bleeding in the chest from surprising and obscure sites. Some are difficult to evaluate and equally difficult to expose and control at the time of any operation, even in the interventional radiology and hybrid OR settings.

Sites for obscure thoracic bleeding include:

Internal thoracic arteryLiver injury over the bare area of the liver and directly into the chest without ANY abdominal bleedingBleeding from vascular anomalies in the chest, such as Diverticulum of KommerellIntercostal arteryAzygos and hemiazygos venous systemErosion of vascularized structures from inserted foreign bodies, such as a tracheostomy tube producing an innominate artery– trachea fistula.

 Internal Hemorrhage from Rib Injury and Intercostal Vascular Bleeding

Injury to intercostal vessels, usually the intercostal arteries, can be produced by all forms of blunt and penetrating trauma, or even iatrogenically at thoracotomy or chest tube insertion. The intercostal artery can bleed at a rate to exceed 200 ml/min. At the time of thoracotomy and with the placement of a chest wall retractor, such bleeding might have abated or be to find and see. Various operative tools, including dental mirrors, might be used to find the exact site of the hemorrhage. The surgeon might even consider a counter, lower incision to aid in finding the bleeding source. If bleeding is from an intercostal artery and not controlled at the first operation, a second look is required. Suture control of an intercostal artery is sometimes very difficult. In such a case, encircle the rib in the area of intercostal artery bleeding on both sides, using an ABSORBABLE suture. The use of a permanent suture will produce chronic pain to the area.

 Azygos Vein Injury

Penetrating trauma and fractures in the area of the azygos vein occur. Although very visible through a right posterolateral incision, surgeons discovering azygos vein injury are most often operating through a median sternotomy, right anterolateral, or even clamshell incision. The azygos vein is very posterior and, if identified, is very much more difficult to suture control. The surgeon should move to the left side of the operating table and ask for the largest, longest needle driver the circulating nurse can find in the OR, and ask for a permanent suture of larger size and with a large round, strong needle. With one hand, pull the right lung to the left, and with the other hand, take a wide, double bite in the area of the azygos vein injury. Tie the knot, reassess bleeding, and repeat this process if necessary.

The azygos and left innominate veins serve as collateral alternate venous return sources to the right heart. If BOTH need vascular control because of injury (or there has been past distant ligation of either), the innominate vein needs to be reconstructed for when both are ligated the venous return to the heart is insufficient.