Traumatic Hemothorax: Reading the Chest Tube That Tells You to Call the OR

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Updated July 2026  |  More ICU clinical guides →

A hemothorax is blood collecting in the pleural space, usually from broken ribs tearing intercostal vessels, from lung laceration, or — the dangerous version — from a great vessel or the heart. It threatens the patient two ways at once: it takes up space, compressing the lung and impairing breathing, and it is ongoing blood loss that can bleed a patient into shock. The chest tube is both the treatment and the monitor: how much comes out, and how fast, is often what decides whether the patient goes to the OR. This guide covers what a hemothorax does, the output numbers that trigger surgery, the drainage-system management the nurse owns, and the retained-blood complications that come later.

What a hemothorax does

Blood entering the pleural space behaves like any pleural collection mechanically — it collapses the underlying lung, reduces the volume available for ventilation, and causes dyspnea, decreased breath sounds, and dullness to percussion (the opposite of the hyperresonance you get with a pneumothorax). A large or rapidly accumulating hemothorax can compress enough to cause respiratory compromise. But the feature that makes hemothorax its own emergency is the second threat: it is active hemorrhage into a body cavity. A chest can hold liters of blood, so a patient can lose their circulating volume into the thorax and present in hemorrhagic shock with a "white-out" on one side of the chest film. That is why hemothorax is managed jointly as a breathing problem and a bleeding problem.

The chest tube as diagnosis, treatment, and monitor

The first move for a significant hemothorax is a chest tube — traditionally a large-bore tube, positioned to drain blood. It does three jobs: it evacuates the blood so the lung re-expands, it prevents blood from clotting and organizing in the pleural space, and — critically for the nurse — it quantifies the bleeding. The volume that drains immediately on insertion, and the rate of ongoing output, are the numbers the surgical team uses to decide between watchful chest-tube management and an operation.

The exact numbers vary by protocol, but the concept is fixed: a big immediate gush or a sustained brisk rate means the patient is bleeding faster than a tube can safely manage, and needs the OR. This is why accurate, timed output measurement by the nurse is not clerical — it is the data that triggers a life-saving decision. Alongside the tube, these patients are resuscitated for hemorrhage: type-specific or emergency-release blood, balanced massive transfusion when they are bleeding heavily, tranexamic acid in the appropriate window, and the principles of damage-control resuscitation. Shed pleural blood can sometimes be collected and autotransfused back to the patient.

Managing the drainage system

Once the tube is in, the nurse runs the water-seal drainage system. Key tasks: measure and time the output and mark the canister, keep the system below the level of the chest and upright, keep tubing free of dependent loops and kinks, and observe the water-seal chamber for tidaling (fluid movement with respiration, a sign of a patent tube) and for an air leak (bubbling, suggesting an ongoing pleural air leak from associated lung injury). Do not routinely clamp or strip the tube; follow facility policy, because inappropriate clamping of a tube with an air leak can create tension physiology, and vigorous stripping generates high negative pressure. Monitor the insertion site for bleeding and subcutaneous air, and track the patient's respiratory status and hemodynamics together with the output.

Retained hemothorax and empyema

Not all the blood always drains. When clot and blood are left behind — a retained hemothorax — two problems follow over days. The blood can organize into a fibrous peel that traps the lung and prevents full expansion (a fibrothorax), and it is an excellent culture medium, so it can become infected into an empyema (pus in the pleural space, with fever, rising white count, and a persistent effusion). Because of this, a significant retained hemothorax is often addressed early with video-assisted thoracoscopic surgery (VATS) to evacuate the clot before it organizes or infects. The nurse contributes by ensuring effective initial drainage, watching for incomplete lung expansion on follow-up imaging, and flagging the fever and clinical signs that suggest a developing empyema.

Where to go from here

Pair this with the tension pneumothorax guide and the flail chest and pulmonary contusion guide for the rest of the chest-trauma picture, the blunt cardiac injury guide for the heart under the same impact, the chest tube management guide for the drainage system in depth, and the massive transfusion protocol guide for resuscitating the blood loss.