The following systemwise presentation of signs and symptoms is seen in patients suffering from hemothorax:

• General appearance: Patients usually presents with anxiety and restlessness due to the profound hypovolemic shock caused by the internal bleeding in the pleural cavity. 
• Integumentary system: The skin will appear pale, cold and clammy due to the impending hypovolemic shock.
• Head and neck: The jugular veins may appear bounding and engorged due to pulmonary hypertension.
• Chest and heart: Chest pain may ensue as the blood collection irritates the pleural nerves. Hypovolemic shock may lead to tachycardia and hypotension in patients with hemothorax. Patients may present with shallow breathing due to the respiratory response of the patient to the space limiting expansion of the blood in the pleura. The region of the hemothorax in the chest may be devoid of breath sounds during auscultation and may be dull upon percussion.
• Renal: Oliguria may be an early sign of hypovolemic shock.
• Extremities: Pulses in the extremities will appear thread-like and weak due to the massive exsanguination of blood within the pleural cavity.
• Neurologic: When patients are brought in the emergency room as unconscious and obtunded, they may be suffering from late symptoms of shock and may require immediate emergency care. 

• Subcutaneous Bleeding

  Hemophilia A manifests with early muscle and subcutaneous bleeding in 70% of cases. Haemothorax is a very rare event occurring in less than 1% of cases. [doi.org]

• Pain

  Shock from hemorrhage, pain, and respiratory failure follow if emergency care is not available. Also spelled haemothorax. [medical-dictionary.thefreedictionary.com]

  A 61-year-old woman presented with thigh pain and gait disturbance due to weakness in her lower right extremity. She was diagnosed with a lumbar disc herniation at L1-2 and the MIS-TLIF procedure was performed. [ncbi.nlm.nih.gov]

  [ncbi.nlm.nih.gov] pain or shortness of breath. [symptoma.com]

  Severe jaw, neck, shoulder or arm pain Difficulty breathing or shortness of breath Go to the emergency room or call the local emergency number (such as 911) if you have: Dizziness, lightheadedness, fever and cough, or a feeling of heaviness in your chest [medlineplus.gov]

• Pallor

  Entire Body System Pallor In the night following admission the patient had acute cardiovascular decompensation with worsening dyspnea, pallor and hypotension. [symptoma.com]

  In the night following admission the patient had acute cardiovascular decompensation with worsening dyspnea, pallor and hypotension. [ncbi.nlm.nih.gov]

  […] than trachea - Gunshot or other wound (hole > 2/3 tracheal diameter) +/- exit wound - Unequal breathsounds - ABG's: decreased pO2 - Air-tight dressing sealed on 3 sides - Chest tube - Surgery Massive Hemothorax - > 1500 cc blood loss in chest cavity - Pallor [fprmed.com]

  Observe carefully for pallor, blood pressure, and pulse rate, noting the early signs of shock or massive bleeding such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. [medical-dictionary.thefreedictionary.com]

• Malaise

  When accompanied by fever and malaise, secondary infection of the pleural fluid should be considered and is associated with increased mortality. [cancertherapyadvisor.com]

  Dyspnea, cough, general malaise and dizziness are obvious in moderate hemothorax. The skin is pale. The hemodynamic disturbances – tachycardia and decreased arterial pressure are observed. [intranet.tdmu.edu.ua]

• Dyspnea

  When ruptured, these cysts may cause hemoptysis, dyspnea, and hydatid thorax. [ncbi.nlm.nih.gov] After thoracoscopic surgery, the dyspnea and anemia resolved. On postoperative day 5, the patient left the hospital. [symptoma.com]

  Patients with hydatid cysts typically present with cough, chest pain, dyspnea, hemoptysis, or allergic reactions. When ruptured, these cysts may cause hemoptysis, dyspnea, and hydatid thorax. [ncbi.nlm.nih.gov]

  On the following day mild dyspnea and chest pain developed, with pain in the right upper abdomen and vomiting. He returned to the same hospital, and erythromycin was prescribed, without benefit. [nejm.org]

• Tachypnea

  [ncbi.nlm.nih.gov] Tachypnea She presented with tachypnea, worsening anemia, and oxygen desaturation. Hemothorax was diagnosed based on chest radiography, ultrasonography, and diagnostic thoracic puncture results. [symptoma.com]

  She presented with tachypnea, worsening anemia, and oxygen desaturation. Hemothorax was diagnosed based on chest radiography, ultrasonography, and diagnostic thoracic puncture results. [ncbi.nlm.nih.gov]

  Tachypnea Shallow rapid breathing due to respiratory distress. Tachypnea Shallow rapid breathing due to respiratory distress. [medicaljoyworks.com]

  Signs and symptoms Tachypnea Dyspnea Cyanosis Decreased or absent breath sounds on affected side Tracheal deviation to unaffected side Dull resonance on percussion Unequal chest rise Tachycardia Hypotension Pale, cool, clammy skin Possibly subcutaneous [drminkim.com]

  Patients who lose 30% of their blood volume are at risk of tachycardia (fast resting heart rate), tachypnea (abnormal or rapid breathing), and decreased pulse pressure. [docdoc.com.sg]

• Tracheal Deviation

  […] in 5th ICS, anterior axillary line [fprmed.com] Complete collapse of the lung may be followed by tracheal deviation and mediastinal shift. [symptoma.com]

  Signs and symptoms Tachypnea Dyspnea Cyanosis Decreased or absent breath sounds on affected side Tracheal deviation to unaffected side Dull resonance on percussion Unequal chest rise Tachycardia Hypotension Pale, cool, clammy skin Possibly subcutaneous [drminkim.com]

  deviation away from pneumothorax - Percussion hyperresonnance - Unilateral absence of breath sounds, hypotension - Non-radiographic diagnosis - large bore IV needle, 2nd ICS mid clavicular line, followed by chest tube in 5th ICS, anterior axillary line [fprmed.com]

  Tracheal deviation. Dull resonance on percussion. Unequal chest rise. Tachycardia. Hypotension. Pale, cool, clammy skin. Possibly subcutaneous air. Narrowing pulse pressure. [bionity.com]

  The first notable finding is tracheal deviation to the right, away from the side where the procedure was performed. This should immediately raise concern for tension physiology as the cause of the acute drop in blood pressure. [knowledgeplus.nejm.org]

• Decreased Breath Sounds

  Patients with large hemorrhage volume are often dyspneic and have decreased breath sounds and dullness to percussion (often difficult to appreciate during initial evaluation of patients with multiple injuries). [msdmanuals.com]

  Shallow breathing and increased tenderness of the left thoracic wall were evident with palpation. Decreased breath sounds on the left and dullness on percussion were also noted. Drs Avra Lykouri, V. Archimandriti, V. Baili, and D. [patientcareonline.com]

  Unilaterally decreased breath sounds may indicate the presence of hemothorax or pneumothorax. If the patient has an endotracheal tube in place, assess the depth ... [accessmedicine.mhmedical.com]

• Abnormal Breathing

  During a physical exam, doctors will listen for sounds of abnormal breathing through a stethoscope. Doctors may also tap on the chest to listen for sounds of liquid. [medicalnewstoday.com]

• Chest Pain

  [ncbi.nlm.nih.gov] In this report, we describe a 34-year-old male patient, who presented to emergency service with sudden chest pain and dyspnea. [ncbi.nlm.nih.gov] Abstract A 58-year-old man presented with right-sided chest pain. [symptoma.com]

  Chest pain or shortness of breath Go to the emergency room or call the local emergency number (such as 911) if you have: Dizziness, fever, or a feeling of heaviness in your chest Severe chest pain Severe difficulty breathing Prevention Use safety measures [indiatoday.in]

  He was seen at another hospital, where plain chest radiographs were normal. On the following day mild dyspnea and chest pain developed, with pain in the right upper abdomen and vomiting. [nejm.org]

  The present case, as well as other previously reported cases, illustrates that sudden-onset dyspnea and chest pain in a previously healthy individual, which co-occurs with acute mediastinal widening on chest roentgenography, may be indicative of ruptured [spandidos-publications.com]

  In this paper, we share a pleural multicystic mesothelial proliferation case arrives the emergency service with sudden chest pain and dyspnea complaint that presented with hemothorax complication. [ncbi.nlm.nih.gov]

• Hypotension

  Marked blood loss produces hypotension and shock. [symptoma.com]

  Remember the principle of permissive hypotension, as excessive fluid resuscitation can wash out clotting factors and lead to further bleeding. [medictests.com]

  […] accumulation of air in pleural space - Respiratory distress, tachycardia, distended neck veins, cyanosis, asymmetry of chest wall motion - Tracheal deviation away from pneumothorax - Percussion hyperresonnance - Unilateral absence of breath sounds, hypotension [fprmed.com]

  ] Hypotensive resuscitation has been suggested for the hemorrhagic shock patient without head trauma. [ncbi.nlm.nih.gov]

• Tachycardia

  [merckmanuals.com] Tachycardia Fluid resuscitation as needed Usually tube thoracostomy Sometimes thoracotomy Patients with signs of hypovolemia (eg, tachycardia, hypotension) are given IV crystalloid and sometimes blood transfusion (see Intravenous Fluid [symptoma.com]

  Tachycardia Due to profuse systemic blood loss, an attempt to keep the circulatory system intact. Tachycardia Due to profuse systemic blood loss, an attempt to keep the circulatory system intact. [medicaljoyworks.com]

  QUICK TIPS: Characteristic signs of a tension pneumothorax are: Jugular Vien Distention (JVD) Hyper-resonance on one side Tachycardia Hypotension Tension pneumothorax is a progressive condition that worsens as each breath increases the pressure inside [medictests.com]

  […] fractures pulmonary contusion pericardial tamponade tracheobronchial injury esophageal injury aortic injury pneumothorax Presentation Symptoms dyspnea pleuritic chest pain lightheadedness Physical exam vital sign abnormalities (e.g., hypotension and tachycardia [step2.medbullets.com]

• Vascular Disease

  […] pleural effusion resulting from diseases of the GI tract pleural effusion resulting from collagen vascular diseases other pathologic fluids that separate the parietal from the visceral pleura Empyema (pus) Chylothorax (milky fluid) Hemothorax (blood) [quizlet.com]

  Coronary Artery Disease or Peripheral Vascular Disease. E. Diabetes or other Endocrine issues. F. Malignancy. G. Immunosuppression (HIV, chronic steroids, etc). H. Primary Lung Disease (COPD, Asthma, ILD). I. Gastrointestinal or Nutrition Issues. J. [cancertherapyadvisor.com]

  Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, et al.; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council [atsjournals.org]

  In general, criteria for operative or interventional treatment for vascular diseases are the presence of symptoms, rupture, or large aneurysm size [3]. [oatext.com]

  The differential diagnosis of hemothorax includes spontaneous pneumothorax, coagulopathy, vascular disease, neoplasia, and miscellaneous. We should use a fast and efficient diagnostic tool at emergency department. [jmedscindmc.com]

• Sweating

  혈흉 다른 곳에서 찾기 네이버사전 다음사전 [百Br] 혈흉증 [ 血胸症, hemothorax ] Compensatory sweating 허벅지, 다리 of the back, abdomen, thighs and legs, 등, 복부에 생기는 보상성 발한과 possible gustatory sweating. 미각 발한의 가능성도 있다 Horner's syndrome occurs in less than 1% of patients. [dic.impact.pe.kr]

  SIGNS&SYMPTOMS • pain or feeling of heaviness in your chest • feeling anxious or nervous • dyspnea, or having trouble breathing • breathing quickly short • abnormally fast heartbeat • breaking out in cold sweats • skin turning pale 19. [slideshare.net]

  […] adhesions, neoplasm, pleural metastasis, and as a complication of anticoagulant therapy for pulmonary embolisms. [4] Clinical Presentation[edit | edit source] Chest Pain Dyspnoea Fever Tachycardia Reduced breath sounds on the affected side Pallor Cold Sweats [physio-pedia.com]

  The most common symptoms of hemothorax include: pain or feeling of heaviness in your chest feeling anxious or nervous dyspnea, or having trouble breathing breathing quickly abnormally fast heartbeat breaking out in cold sweats skin turning pale high fever [healthline.com]

• Agitation

  The AgiTube, will use a combination of mechanical agitation, optional multidirectional saline spray, and suction to slow the clotting process, prevent gelling of blood, and maintain drainability. * Information listed above is at the time of submission [sbir.gov]

  Presumably as a result of physical agitation produced by movement of the heart and the lungs, the clot may be defibrinated. Loculation occurs early in the course of hemothorax, as with empyema. [thoracickey.com]

  Contrast echocardiography with injection of agitated saline (to create bubble) in peripheral vein was done. Bubbles appeared in left atrium after fourth cardiac cycle suggestive of a right to left shunt. [lungindia.com]

  The agitation of cardiac and respiratory movement rapidly defibrinates the blood, and a fibrin clot thus formed is deposited on the visceral and parietal pleura, setting the stage for a trapped lung. [resmedjournal.com]

A good clinical history and physical examination may easily seal the diagnosis of hemothorax. However, these laboratory tests and examinations may prove to be helpful in the definitive diagnosis and the management of the hemothorax:

• Chest radiograph (X-ray): This imaging modality may reveal the exact location of the hemothorax and give the clinician the idea on the extent of the injury to the lungs.
• Computed tomography (CT-scan):  This confers a more detailed view of the lung parenchyma and the major vessels that might have been severed to cause the blood collection in the pleural space. The CT scan can accurately compute the volume exsanguinous blood in the pleural space.
• Pleural tap or thoracentesis: The laboratory analysis of the pleural fluid will confirm whether the blood in the pleura is a true hemothorax or just a bloody pleural effusion.

• Atelectasis

  Mild atelectasis is seen adjacent to the hemothoraces and likely small volume pulmonary contusion in the right lung base where a small traumatic pneumatocele is seen. [radiopaedia.org]

  Results revealed a large, multiloculated, right-sided pleural effusion with compression atelectasis of the right lung without underlying pneumonia. Figure 1. [consultant360.com]

  Figure 2: A chest computed tomographic scan shows left-sided pleural effusion with passive atelectasis. Figure 3: Aspirated pleural effusion shows grossly bloody aspirate. [tgkdc.dergisi.org]

  In penetrating chest injuries, morbidity was slated at 8.51% complicating to either atelectasis, lung infection, intrathoracic hematoma, wound infection, pneumothorax, or sepsis. [symptoma.com]

• Hypoalbuminemia

  Transudates imply hydrostasis (eg, left ventricular failure, hypoalbuminemia) while exudates imply capillary permeability (eg, malignancy, parapneumonic effusion). On imaging, this distinction can be difficult. [appliedradiology.com]

  Additional mechanisms are thought to contribute to pleural fluid accumulation in hepatic hydrothorax including hypoalbuminemia (decreased colloid osmotic pressure), perito-pleural lymphatic drainage and azygous vein hypertension with plasma leakage, since [cancertherapyadvisor.com]

Patients presenting in the emergency room with signs of hemothorax should be dealt with promptly. The stabilization of the cardiopulmonary status is given utmost priority followed by the prompt evacuation of the collected blood and pneumothorax in the pleural space. The application of a tube thoracostomy in patients with hemothorax remains to be the primary mode of treatment.

The use of a Video Assisted Thoracoscopic Surgery (VATS) allows the direct removal of clots in the pleura and the precise placement of the chest tubes. VATS may also be used in the direct ligation of chest bleeders to control the progression of hemothorax in some cases [6]. Even in late cases of retained clots, VATS may prove to be useful to evacuate these clots when the patient is already stabilized [7].

In cases of non-traumatic hemothorax, the open thoracotomy approach may prove to be indispensable. This procedure is most useful in the following intrathoracic surgical procedures: stapling of bullous lesions, resection of cavitary diseases and necrotic lung tissue, sequestration of arterio-venous malformation, and repair of aortic aneurysm [8].

Residual pneumothorax is treated by fibrinolysis through the chest tube using streptokinase or urokinase in saline solution [9]. The regular instillation of fibrinolytic compounds in the pleura carries a success rate of up to 92%.

In general, the outcome for traumatic hemothorax is good due to the advances in the health care delivery. Mortality rates in hemothorax varies directly to the severity of the thoracic injury and the important structures involved therein. Retained hemothorax, empyema and fibrothorax is associated with poor morbidity rating. The prompt surgical evacuation of the retained hemothorax is associated with an excellent prognosis.

Complications

The following medical conditions are known to be the common complications of hemothorax:

• Atelectasis
• Retained hemothorax
• Respiratory failure
• Fibrothorax or scarring of the pleural membrane
• Empyema
• Pneumothorax
• Hypovolemic shock
• Death

The following clinical conditions may contribute or directly cause hemothorax in patients:

• Chest trauma
• Blood dyscrasias or clotting defects
• Heart or lung surgery (iatrogenic)
• Pulmonary ischemia or infarction
• Pulmonary or pleural cancers
• Vascular tear
• Tuberculosis

In the United States, the number of hemothorax cases related to chest trauma approximates 300,000 cases per year [3]. Statistics in a trauma center have confirmed that the relative mortality rate of hemothorax among children reaches 57.1% in blunt chest trauma [4]. In penetrating chest injuries, morbidity was slated at 8.51% complicating to either atelectasis, lung infection, intrathoracic hematoma, wound infection, pneumothorax, or sepsis [5].

The pathophysiology of hemothorax is governed by two basic responses namely: the hemodynamic response, and the respiratory response. Any disruption in the integrity of the chest wall to the lung parenchyma may cause significant bleeding that can fill the pleural space. Given that the pleural cavity can hold up to 4 liters of fluids, an occult exsanguination of blood can cause hypovolemic shock to a patient without eminent bleeding from the outside. Shock can occur if blood loss amounts to more than 30% of the blood volume or approximately 1,500 ml in a 70kg man.

Early symptoms of shock includes tachypnea, tachycardia and decreased pulse pressure. While the blood collects in the pleural space, the lung parenchyma is consequently displaced and unable to expand effectively. The significant impairment in the oxygen exchange in the lungs due to the collection of blood constitutes the respiratory response phase of the hemothorax.

Traumatic hemothorax can be prevented by avoiding activities that may lead to blunt injuries to the chest wall. Seat belts must always be in place while driving. Drivers must cautiously drive motorcycles and bicycles to avoid road accidents. Patients diagnosed with tuberculosis must submit to immediate treatment and constant chest X-ray monitoring to prevent spontaneous hemothorax and pneumothorax [10].

Hemothorax is a clinical condition characterized by the presence of blood between the chest wall and the lung parenchyma (pleural space). The hemorrhage in hemothorax may originate from the lung parenchyma, the great vessels, the heart or the chest wall.

Hemothorax is usually caused by blunt trauma to chest wall but may infrequently be due to diseases conditions, iatrogenic induction or spontaneous [1]. Hemothorax needs immediate evacuation to prevent life threatening complications. To this day, the use of trocar and cannula through an incision in the chest wall to drain the blood and trapped air is still the standard practice [2].

Definition

Hemothorax is defined as a clinical condition characterized by the presence of blood in the pleural space.

Cause

Chest trauma, bleeding defects, chest surgery, pulmonary infarction, cancers and vascular problems are common causes.

Symptoms

Patients will present in anxiety and is usually restless. Signs of shock may ensue with a progressively bleeding hemothorax.

Diagnosis

A thorough clinical history and physical examination. Ancillary procedures like laboratory pleural fluid analysis and imaging techniques may also be implored.

Treatment and follow-up

Tube thoracostomy remains to be the primary mode of treatment, Open thoracotomy may also be an option, the use of VATS for hemothorax evacuation in stabilized patients may also be done, and pleural fibrinolysis may also be done to eliminate the residual pneumothorax. 

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2. Rusch VW, Ginsberg RJ. Chest wall, pleura, lung and mediastinum. In: Schwartz SI, ed. Principles of Surgery. 7th Ed. New York, NY: McGraw-Hill; 1999:667-790.
3. Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex thoracic injuries. Surg Clin North Am. Aug 1996; 76(4):725-48.
4. Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Garcia VF, Bowman LM. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg. Sep 1990; 25(9):961-5; discussion 965-6.
5. Inci I, Ozcelik C, Nizam O, Eren N, Ozgen G. Penetrating chest injuries in children: a review of 94 cases. J Pediatr Surg. May 1996; 31(5):673-6.
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7. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. Jul 2004; 78(1):282-5; discussion 285-6.
8. Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex thoracic injuries. Surg Clin North Am. Aug 1996; 76(4):725-48.
9. Inci I, Ozçelik C, Ulkü R, Tuna A, Eren N. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax.Chest. Jul 1998; 114(1):160-5.
10. Issaivanan M, Baranwal P, Abrol S, Bajwa G, Baldauf M, Shukla M. Spontaneous hemopneumothorax in children: case report and review of literature. Pediatrics.