Evidence‑Based Management of Massive Hemothorax

Immediate Resuscitation and Stabilization

Control obvious external bleeding with direct pressure, tourniquets, or hemostatic dressings. 1
Obtain large‑bore intravenous access (maximum gauge, 8‑Fr central line in adults); if peripheral access fails, use intra‑osseous or surgical venous access. 3
Deliver high‑flow oxygen to all patients. 2
Assess perfusion clinically: consciousness, ability to speak, and a palpable peripheral pulse indicate adequate perfusion; normal blood pressure is not required before definitive hemorrhage control. 3

Draw baseline laboratory studies immediately: complete blood count, PT, aPTT, Clauss fibrinogen (avoid derived fibrinogen), and type‑and‑cross‑match. 1
Perform point‑of‑care coagulation testing (TEG or ROTEM) when available to guide hemostatic therapy. 2
If the patient is hemodynamically stable enough, proceed to whole‑body CT imaging; otherwise, move directly to operative intervention. 4

Insert a chest tube without delay for any massive hemothorax (initial drainage > 1500 mL or CT‑estimated volume > 300 mL). Surgical exploration is reserved for ongoing bleeding > 300 mL/h for ≥ 4 h, initial drainage > 1500 mL, or persistent hemodynamic instability despite resuscitation. 1
Actively warm the patient and all transfused fluids using approved blood‑warming devices equipped with a visible temperature display and audible alarm. 5

Activate a massive transfusion protocol using warmed blood components; start with uncross‑matched O‑type blood, then group‑specific, and finally cross‑matched units as they become available. 2
Prevent dilutional coagulopathy by administering fresh‑frozen plasma early and maintaining Clauss fibrinogen > 1.5 g/L. 4
Give tranexamic acid 1 g over 10 min followed by 1 g over 8 h when accelerated fibrinolysis is suspected. 8
Withhold vasopressors until active bleeding is controlled. 3

Perform emergency thoracotomy (resuscitative thoracotomy) for patients in cardiac arrest or with imminent arrest. 11
In unstable patients with progressive massive hemorrhage, use an anterolateral left thoracotomy or a clamshell incision for damage‑control thoracotomy. 11

Admit the patient to a critical‑care unit for continuous monitoring of coagulation parameters, hemoglobin, arterial blood gases, and chest‑tube output. 4
Initiate pharmacologic venous thromboprophylaxis as soon as bleeding is adequately controlled. 1

Do not normalize blood pressure before hemorrhage control, as this may exacerbate bleeding. 4
Always measure fibrinogen with the Clauss method; derived fibrinogen values are misleading and should be avoided. 2