In Delayed Traumatic Haemothorax is Chest Drain always the Treatment of Choice?
Date First Published:
December 2, 2009
Last Updated:
December 2, 2009
Report by:
Dr Imogen Bowring, ST5 ED (Chesterfield Royal Hospital)
Search checked by:
Dr Kate Rakin, Chesterfield Royal Hospital
Three-Part Question:
In a [patient with delayed Haemothorax] is [chest drain compared to conservative treatment] the [optimum treatment]?
Clinical Scenario:
A 56 yr old man presents to the emergency department one week after an initial blunt left sided chest injury. Initial investigations showed no haemothorax and he had been discharged with analgesia. On his representation he was complaining of new chest pain and shortness of breath on exertion. His repeat Chest x-ray showed a haemothorax. The question was posed as to whether the correct treatment should be drainage or not.
Search Strategy:
Embase t1974 – present day
Medline tall years to- present day
‘hemothorax and delayed and treatment’
Medline tall years to- present day
‘hemothorax and delayed and treatment’
Outcome:
Embase t16 titles
Medlinet25 titles
Non directly answered the question but 3 were felt to be of significant interest.
Medlinet25 titles
Non directly answered the question but 3 were felt to be of significant interest.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Delayed haemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity. Simon B.J., Chu Q., Emhoff T.A., Fiallo V.M., Lee K.F. 1998 USA | Patients with haemothorax consequent to blunt trauma | Retrospective review of 36 consecutive patients with heamothorax | DHT 18hr – 6 day post injury All needed chest drains | Retrospective case series | |
| A prospective analysis of occult pneumothorax, delayed pnuemothorax and delayed haemothorax after minor blunt thoracic trauma. Misthos P., Kakaris S., Sepsas E., Athnassiadi K., Skottis I 2004 Greece | Patients with blunt thoraxic trauma not needing initial inpatient management, 2yr period. | Prospective case series review | 7.4% presented upto 14 days post injury with DHT. 80% chest tube drainage, 16% thoracocentesis, 4% subsequent 1 month decortication | Small population size | |
| Prevanlence of delayed haemothorax in blunt thoraxic trauma. Sharma O.P, Hgler S., Oswanski M. F 2005 USA | Patients with blunt thoraxic trauma, 8yr period | Retrospective case series review | DHT rate 5% but 86% survive to discharge Suggest timely diagnosis and treatment essential | Retrospective case series |
Author Commentary:
From the search of the literature it can be seen that delayed haemothorax is a recognised if rare presentation. There are no controlled trials to compare drainage of delayed haemothoraxies with conservative treatment. However those papers that were found to be of interest suggested that they should be treated as acute heamothoraxies (Simon et al) and that they have significant morbidity associated with them (Misthos et al).
Misthos et al would recommend immediate evacuation of the pleural space in order that serious complications can be avoided. They site Simon et al as the reference behind this statement. Simon et al say that all their patients required thoracostomy and had prolonged stays in hospital. 5 out of 12 of their cases were immediately life threatening with the drainage of more than 1L or the occurance of significant hypotension.
There needs to be more research into delayed haemothorax as opposed to acute haemothorax to be able to answer the above question fully. However the papers reviewed would suggest that drainage is the recommended treatment at present.
Misthos et al would recommend immediate evacuation of the pleural space in order that serious complications can be avoided. They site Simon et al as the reference behind this statement. Simon et al say that all their patients required thoracostomy and had prolonged stays in hospital. 5 out of 12 of their cases were immediately life threatening with the drainage of more than 1L or the occurance of significant hypotension.
There needs to be more research into delayed haemothorax as opposed to acute haemothorax to be able to answer the above question fully. However the papers reviewed would suggest that drainage is the recommended treatment at present.
Bottom Line:
There is no paper to directly answer the question, however the references would suggest that all delayed haemothoraxies should be treated as acute ones would be and drainage of the pleural cavity immediately undertaken.
References:
- Simon B.J., Chu Q., Emhoff T.A., Fiallo V.M., Lee K.F. . Delayed haemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity.
- Misthos P., Kakaris S., Sepsas E., Athnassiadi K., Skottis I. A prospective analysis of occult pneumothorax, delayed pnuemothorax and delayed haemothorax after minor blunt thoracic trauma.
- Sharma O.P, Hgler S., Oswanski M. F. Prevanlence of delayed haemothorax in blunt thoraxic trauma.