How is a retained clot of hemothorax managed?

Updated: Jul 13, 2020
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: Jeffrey C Milliken, MD  more...
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Approximately 20% of patients who initially have tube thoracostomy for drainage of hemothorax will have some amount of residual clot in the thoracic cavity. Some controversy exists regarding the management of retained clot after tube thoracostomy. Opinions range from conservative watchfulness to additional chest tube placement to surgical evacuation. Current opinion seems to favor some form of clot evacuation.

Many trauma centers are moving away from additional tube thoracostomy and, instead, advocating an early VATS procedure. This is usually performed within 7-8 days of the initial injury and, in some centers, is performed within 48-72 hours if a retained clot is identified within the thorax. [38, 39, 40, 41] However, VATS may be successful even in patients presenting late after injury. [42]

For VATS evacuation of the hemothorax or retained clot, one-lung ventilation is not required. A single-lumen tube can be used with directions to the anesthesiologist to decrease tidal volume or intermittently hold ventilation during the procedure. If cardiac, great vessel, or tracheobronchial injury is found, conversion to thoracotomy can be performed expeditiously.

The decision to perform early evacuation of retained hemothorax with VATS technology is likely to greatly diminish the number of patients who develop the sequelae of empyema and fibrothorax. Although it adds an operative procedure to the patient's management, this approach provides definitive treatment while avoiding the morbidity of a formal thoracotomy, and it shortens the total hospital stay when compared with more conservative management methods.

Patients undergoing surgical intervention for retained hemothorax in either an acute or late setting are monitored in the same fashion as any patient who has undergone VATS or thoracotomy. Generally, the chest tube is removed when drainage is less than 100-150 mL in 24 hours. A chest radiograph is often obtained after removal. Additional chest x-rays films are obtained as previously noted. Care of the thoracic incision(s) is the same as for any thoracic surgical case.

If conservative management of retained collections is chosen, serial chest x-rays should be obtained to assure that resolution is occurring. Once the pleural collection has resolved, a recurrence is unlikely and the patient may be discharged. Increase in size of the collection, development of an air-fluid level, or the new onset of symptoms (eg, fever, cough, dyspnea, pleuritic pain) may warrant CT evaluation and reassessment for surgical intervention.

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