Hemothorax is generally due to bleeding from the pulmonary parenchyma or the chest wall. In most cases bleeding will stop spontaneously once the lung has been re-expanded using tube thoracostomy. However, as indicated previously, ongoing bleeding is an indication for thoracotomy.

If the initial chest tube does not adequately drain the hemothorax, additional tubes should be placed in an effort to clear the blood completely. Patients who have a retained hemothorax are at risk of the development of empyema or a fibrothorax with lung entrapment. If the hemothorax persists despite efforts to obtain complete drainage, it is likely that the blood in the pleural space has clotted. Some have advocated early operative intervention to remove the clotted hemothorax. If an operation is undertaken within the first few days after an injury, the blood clot is usually not very adherent to the pleura and lung, and can be removed quite easily. Indeed, it may be possible to evacuate the clot using thoracoscopy and thereby avoid a thoracotomy incision. If early intervention to remove a retained clot is not undertaken, it may be best to wait for up to 6 weeks before undertaking thoracotomy. The operation is usually easier to perform once the initial inflammatory reaction has subsided, and in some cases the patient will resorb the clot during this period and not require an operation.

Another common reason for delayed operation in patients with chest injuries is an empyema. This may occur following either blunt or penetrating injuries, although it is somewhat more common after the latter. Thoracentesis should be performed if a patient has a new or retained pleural effusion and systemic signs of infection. The pleural fluid is tested for pH, protein, and lactate dehydrogenase levels, and sent for culture. Appropriate antibiotics should be administered if the fluid is infected. Initially, an attempt should be made to drain the infected pleural fluid using closed-tube thoracostomy. Non-operative management has a lower likelihood of success when there is a significant amount of retained clot, if the fluid is quite viscous, or if it has a low pH. Operatively, a localized posterior empyema may be approached with a posterior rib resection and open drainage. A larger empyema generally requires thoracotomy with decortication and drainage, particularly if an extensive pleural peel has developed.

The use of antibiotics at the time of chest tube insertion has been advocated as a means of decreasing the risk of empyema and other infections. Several prospective studies have failed to demonstrate that prophylactic antibiotics prevent subsequent infections. In contrast, a recent meta-analysis of selected studies suggested that there was a statistically significant decrease in the incidence of empyema among patients receiving antibiotic prophylaxis prior to chest tube insertion. Thus the role of antibiotics remains controversial.

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