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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 1974 – present day
Medline all years to- present day
‘hemothorax and delayed and treatment’

Search Outcome

Embase 16 titles
Medline 25 titles
Non directly answered the question but 3 were felt to be of significant interest.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Simon B.J. 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
Misthos P. 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
Sharma O.P 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

Comment(s)

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.

Editor Comment

KMJ

Clinical 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

1. 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. The Journal of Trauma: Injury, Infection, and Critical Care Volume 45(4), October 1998, pp 673-676
2. 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. European Journal of Cardio-Thoracic Surgery 2004;25:859-864
3. Sharma O.P, Hgler S., Oswanski M. F Prevanlence of delayed haemothorax in blunt thoraxic trauma. American Surgeon 2005 vol/is 71/6 (481-486), 0003-1348