Management of Hemothorax

Introduction

The British Thoracic Society provides guidelines for the management of hemothorax, including recommendations for chest tube placement, antibiotic selection, and drainage management 1, 2

Small-bore catheters (10-14F) inserted under imaging guidance are preferred for loculated collections, as recommended by the British Thoracic Society 1
Chest drains should only be inserted by adequately trained personnel, according to the British Thoracic Society 2
Initial drainage should be limited to 10ml/kg, then the drain should be clamped for 1 hour, according to the British Thoracic Society 2
A bubbling chest drain should never be clamped, as stated by the British Thoracic Society 2

For community-acquired infections, the British Thoracic Society recommends cefuroxime + metronidazole or amoxicillin + clavulanic acid 1
For hospital-acquired infections, the British Thoracic Society recommends piperacillin/tazobactam or broader coverage 1
Intravenous antibiotics covering Streptococcus pneumoniae are recommended, and broader spectrum antibiotics should be used for hospital-acquired infections, as suggested by the British Thoracic Society 2
Avoid aminoglycosides due to poor pleural penetration, and consider vancomycin IV or linezolid 600 mg PO/IV twice daily for suspected or confirmed MRSA empyema, as recommended by the Infectious Diseases Society of America 1, 3, 4
Antibiotic selection should be based on susceptibility testing when a pathogen is identified in blood or pleural fluid, as recommended by the British Thoracic Society 5

Small-bore percutaneous drains should be inserted under ultrasound guidance, and connected to a unidirectional flow drainage system kept below chest level, as recommended by the British Thoracic Society 2
Chest tube removal criteria include absence of air leak and <1mL/kg/24h of pleural fluid drainage, or 25-60mL total in a 24-hour period, as recommended by the British Thoracic Society 5
Intrapleural fibrinolytics are recommended for complicated parapneumonic effusion or empyema, as stated by the British Thoracic Society 2
Urokinase can be used twice daily for 3 days (6 doses total), with dosing of 40,000 units in 40 ml saline for children ≥10 kg, and 10,000 units in 10 ml saline for children <10 kg, according to the British Thoracic Society 2

Surgical consultation should be considered if there is persistent sepsis despite drainage and antibiotics, and may require thoracotomy and decortication for organized empyema, as recommended by the British Thoracic Society 2
Consider surgical intervention, such as video-assisted thoracoscopic surgery (VATS) or thoracotomy with decortication, if medical management fails in the presence of fibrinous peel, as recommended by the British Thoracic Society 1

Patients should be followed up daily with assessment of vital signs and clinical symptoms, and monitoring of drainage output and characteristics for empyema, until complete recovery and normalization of chest radiograph, according to the British Thoracic Society 2
Daily assessment of vital signs, pain levels, and laboratory markers (WBC, CRP) is recommended, as well as monitoring drainage output and characteristics, and repeat imaging to assess resolution of fluid collection, as recommended by the British Thoracic Society 2, 6, 1
Ongoing management includes monitoring drainage output and clinical response, ensuring tube patency by flushing with saline if needed, considering a CT scan if drainage is inadequate, and considering intrapleural fibrinolytics if loculations persist, with the goal of preventing further loculations and fibrin deposition, as recommended by the British Thoracic Society 1
The treatment duration for empyema is typically 2-4 weeks, depending on drainage adequacy and clinical response 5

Underlying diagnoses such as immunodeficiency or cystic fibrosis should be considered if there is a poor response to treatment, as suggested by the British Thoracic Society 2
Routine measurement of platelet count and clotting studies is only needed in patients with known risk factors, as recommended by the British Thoracic Society 2
For persistently ill patients without microbiologic diagnosis, consider bronchoalveolar lavage (BAL) for mechanically ventilated patients, percutaneous lung aspirate, or open lung biopsy in critically ill, mechanically ventilated patients, as recommended by the British Thoracic Society 5