If no serious underlying vascular defect is detected, drainage of the pleural space can be undertaken using a chest drain or aspiration needle. Blood does not usually drain from the pleural space due to gravity alone but escapes with the re-expansion of the lung. Provided that loculation has not occurred, this process usually takes a short period of time unless there is continued intrapleural bleeding. Chest drainage should be through a tube large enough to allow patency and to permit some clots to be evacuated, but the pain that overlarge intercostal drains may cause should also be taken into account. Inadequate drainage is more common following needle aspiration than following intercostal tube insertion. Liquefied blood may be removed by needle aspiration. The use of an underwater seal is not essential. In many parts of the world sterile water can be difficult to obtain. A study of a drainage bag with a valve incorporated has shown good results ( Gl§Mm eLa.l.: 1992). In the critical care area such bags simplify the environment around the patient. There is controversy over the necessity of controlling the rate of fluid removal. No good data are available. Rapid drainage of hemothoraces that have accumulated rapidly seems safe. However, it may be wiser to restrict drainage to 500 ml/h in those that have accumulated gradually with a relatively 'fixed' pleural space.

When patients remain well with hemothoraces, the blood is often broken down and gradually reabsorbed without complication. Fibrin can form and a fibrothorax can ensue, so that in critical care management it is best to remove blood by aspiration or chest tube insertion or, if this fails, by thoracoscopic division of loculi and large clots (McManusandMcGuigan 1994). Where thoracoscopy is not available thoracotomy should be considered. From our trauma experience in Belfast, thoracotomy is best when carried out within 4 days of hemothorax formation or about 8 weeks after formation when an organized 'cortex' can be completely removed. Early thoracoscopy for hemothorax may save significant numbers of patients from more major procedures (Webb When surgery is carried out between these window periods, there are greater problems in dealing with edematous collapsed lung, further hemorrhage, and infection. When infection supervenes, tube drainage with the aid of a single short rib resection simplifies management. Only a small percentage will progress to require decortication. The management of hemothorax will vary according to the condition of the patient and the surgical and anesthetic skills available. Where experienced thoracic surgeons are available the added morbidity and mortality of a thoracotomy is low. Xa.bJe...3 sets out a suggested management plan for this scenario. However, this is not a universal solution. Elsewhere, conservative management may be the safer method.

Table 3 Suggested drainage procedures

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