Fig 11. Haemothorax on a supine

Common, typically caused by intercostal vessel injury (high arterial pressure system, and therefore potentially brisk bleeding) or more rarely, lung laceration (low arterial pressure system).

Two errors in CXR interpretation:

  • Failing to recognize haemothorax on a supine CXR (image)
  • Underestimating the size of haemothorax. Blunting of a costophrenic angle on an erect CXR requires at least 300 ml of blood


If a haemothorax is large enough to be visible on CXR, then insert a large bore chest drain (28-32F) using the traditional surgical technique in order to [6]:

  • Evacuate the blood, so preventing a clotted haemothorax (and consequent lung entrapment +/- empyema)
  • Monitor blood loss

Give prophylactic antibiotics as guided by your local antibiotic prescribing policy.

Enrol the support of thoracic surgical colleagues for >moderate haemothorax.  ATLS [5] recommends thoracotomy for:

  • Prompt drainage of 1500 ml blood
  • >200 ml/hr blood loss for 2-4 hrs
  • Continued need for blood transfusion

Do not forget that empyema rates following chest drain insertion for any traumatic indication is approximately 2.5% – give your patients prophylactic antibiotics (cephalosporins or clindamycin) [7].

Learning bite

A haemothorax visible on chest x-ray requires a large bore chest drain.

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