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# Haemothorax

A hemothorax is blood collected between the lung and the chest wall, usually after chest trauma; a large bleed compresses the lung and causes shock.

Updated 2026-10-29

## Structures involved

Tap one to see what it is and open it in 3D.

- [Pleura](https://durgical.com/en/anatomy/pleura/)
- [Posterior intercostal arteries](https://durgical.com/en/anatomy/posterior-intercostal-arteries/)
- [Internal thoracic artery](https://durgical.com/en/anatomy/internal-thoracic-artery/)
- [Intercostal veins](https://durgical.com/en/anatomy/right-posterior-intercostal-veins/)
- [Ribs (back part)](https://durgical.com/en/anatomy/ribs/)
- [Thoracic aorta](https://durgical.com/en/anatomy/thoracic-aorta/)

## In the clinical exam

- [Pleural effusion syndrome](https://durgical.com/en/clinical-exam/pleural-effusion-syndrome/)

## In physiology

- [Pleural fluid: formation and drainage](https://durgical.com/en/physiology/pleural-fluid-formation-and-drainage/)

## Why it happens

- [Hemorrhage: petechiae, purpura, ecchymosis, hematoma, and what blood loss does](https://durgical.com/en/general-pathology/hemorrhage-petechiae-purpura-ecchymosis-hematoma-and-what-blood-loss-does/)
- [Shock: types, stages and the organs it damages](https://durgical.com/en/general-pathology/shock-types-stages-and-the-organs-it-damages/)
- [Serous membranes: pleura and peritoneum](https://durgical.com/en/histology/serous-membranes-pleura-and-peritoneum/)

## What it is

Blood in the pleural space, most often after chest trauma. A large amount compresses the lung and causes shock; massive haemothorax is a life-threatening emergency.

## Who gets it

Common after both blunt and penetrating chest trauma; in Colombia and Latin America, stab and gunshot wounds are a frequent cause in emergency departments. Non-traumatic haemothorax is rare.

## Causes

- Blunt trauma with rib fractures and torn intercostal vessels
- Penetrating trauma: stab and gunshot wounds
- Injury to lung, [internal thoracic artery](https://durgical.com/en/anatomy/internal-thoracic-artery/), heart or great vessels
- Iatrogenic: central lines, chest drains, pleural biopsy, thoracic surgery
- Non-traumatic: tumours, anticoagulation, aortic rupture, ruptured vascular malformation

## Risk factors

- Chest trauma
- Rib fractures
- Anticoagulant or antiplatelet use
- Bleeding disorders
- Pleural or thoracic procedures
- Pleural or lung tumours

## Pathophysiology

Bleeding from intercostal or internal thoracic arteries, lung tissue or great vessels collects in the pleural space, which can hold a large part of the circulating volume. Blood loss causes hypovolaemic shock and the collection compresses the lung. Blood that is not drained clots and organises, causing retained haemothorax, empyema or a trapped lung.

## Classification

- Traumatic, iatrogenic or spontaneous
- Small, moderate or large by volume
- Massive haemothorax (large initial drainage or ongoing bleeding; thresholds vary)
- Retained (clotted) haemothorax

## Symptoms and signs

- Chest pain and shortness of breath
- Reduced breath sounds on the affected side
- Dullness to percussion
- Tachycardia and hypotension
- Signs of the causative injury

## Red flags

- Shock or hypotension
- Large initial blood drainage from the chest tube
- Ongoing bleeding through the drain
- Penetrating wound medial to the nipples or scapulae (heart and great vessels)
- Associated tension pneumothorax

## Diagnosis

**Clinical**
Trauma with reduced breath sounds, dullness and shock. In trauma the primary survey and eFAST come first.

**Tests**
Blood count and crossmatch; pleural fluid haematocrit (a value of about half the blood haematocrit or more is the usual definition); coagulation studies.

**Imaging**
Bedside ultrasound (eFAST) detects fluid quickly; upright [chest](https://durgical.com/en/anatomy/region/chest/) X-ray shows blunting or opacity, while a supine film may show only diffuse haziness; CT for stable patients and retained blood.

## Differential diagnosis

- Pleural effusion
- Empyema
- Pneumothorax
- Lung contusion
- Diaphragmatic rupture

## Goal of treatment

Restore circulating volume, drain the blood to re-expand the lung, stop ongoing bleeding and prevent retained haemothorax and empyema.

## Treatment

**Acute**
Trauma resuscitation with blood products and treatment of coagulopathy.

**Procedure**
Chest tube (tube thoracostomy) to drain the blood, measure losses and re-expand the lung; very small collections may only be watched.

**Surgical**
Thoracotomy or video-assisted surgery for massive haemothorax or ongoing bleeding, using thresholds set by trauma guidelines.

**Procedure**
Early video-assisted thoracoscopic evacuation of retained clotted blood; intrapleural fibrinolytics in selected cases.

**Follow-up**
Repeat imaging, drain output records and watch for fever (empyema).

## Complications

- Hypovolaemic shock
- Retained haemothorax
- Empyema
- Fibrothorax and trapped lung
- Respiratory failure

## Prognosis

Depends on the source of bleeding and associated injuries. Most patients do well with a chest tube alone; delayed drainage of retained blood increases the risk of empyema and fibrothorax.

## Prevention

- Road safety and violence prevention
- Ultrasound guidance for pleural and central line procedures

## Test yourself

Think of the answer, then tap the question to see it.

## What is the first-line procedure for a traumatic haemothorax?

A chest tube (tube thoracostomy) to drain the blood, re-expand the lung and monitor ongoing bleeding.

## When does a haemothorax usually need surgery?

When it is massive on drainage or bleeding continues, by thresholds set in trauma guidelines, or when clotted blood is retained.

## How is haemothorax defined from pleural fluid?

By a pleural fluid haematocrit of about half or more of the blood haematocrit.

## What can happen if a haemothorax is not fully drained?

Retained clot can become infected (empyema) or organise into a fibrothorax that traps the lung.

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## Related conditions

- [Rib fractures](https://durgical.com/en/conditions/rib-fractures/)
- [Pneumothorax](https://durgical.com/en/conditions/pneumothorax/)
- [Pleural effusion](https://durgical.com/en/conditions/pleural-effusion/)
- [Hypovolaemic shock](https://durgical.com/en/conditions/hypovolaemic-shock/)
- [Aortic dissection](https://durgical.com/en/conditions/aortic-dissection/)
- [Flail chest](https://durgical.com/en/conditions/flail-chest/)
- [Cardiac tamponade](https://durgical.com/en/conditions/cardiac-tamponade/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Hemothorax](https://www.ncbi.nlm.nih.gov/books/NBK538219/) (StatPearls (NCBI Bookshelf), 2023).

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Source: https://durgical.com/en/conditions/haemothorax/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/haemothorax/