Hemothorax


A hemothorax is a type of pleural effusion in which blood accumulates in the pleural cavity This excess fluid can interfere with normal breathing by limiting the expansion of the lungs The term is from hemo- + thorax

Contents

  • 1 Signs and symptoms
  • 2 Cause
  • 3 Mechanism
  • 4 Diagnosis
  • 5 Management
  • 6 Prognosis
  • 7 See also
  • 8 References

Signs and symptomsedit

Hemothorax tends to occur following blunt or penetrating trauma to the thorax or thoracoabdominal area2 It may also follow thoracic surgery, or may be spontaneous Chest pain, dyspnea, and tachypnea are common presenting features Other symptoms of hemothorax are dependent on the mechanism of injury, but may include:

  • Cyanosis
  • Decreased or absent breath sounds on affected side
  • Tracheal deviation to unaffected side
  • Dull resonance on percussion
  • Unequal chest rise
  • Tachycardia
  • Hypotension
  • Pale, cool, clammy skin
  • Possible subcutaneous emphysema
  • Narrowing pulse pressure

Causeedit

Its cause is usually traumatic, from a blunt3 or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs This rupture allows blood to spill into the pleural space, equalizing the pressures between it and the lungs Blood loss may be massive in people with these conditions, as each side of the thorax can hold 30 to 40% of a person's blood volume or 15 to 2 L per side in the average adult Even minor injury to the chest wall can lead to significant hemothorax4

Less frequently, hemothorax occurs spontaneously A major vascular cause of hemothorax is aortic dissection or rupture of thoracic aortic aneurysms2 It may also follow surgical intervention in the thoracic area Infrequently, patients with pneumothorax may develop spontaneous hemothorax Spontaneous hemothorax or hemopneumothorax may be occur with endometriosis, if endometrial tissue implants on the pleural surface, then bleeds in response to cyclical hormonal changes in menstruating women5

Mechanismedit

The thoracic cavity is a chamber within the chest, containing the lungs, heart, and numerous major blood vessels The parietal pleura lines the chest wall, while the visceral pleura covers the outside of the lungs The visceral and parietal pleura are separated by a thin layer serous fluid When a hemothorax occurs, blood enters the pleural cavity, which normally only contains a small amount of pleural fluid As blood builds up within the pleural cavity, it begins to interfere with the normal movement of the lungs, resulting in dypsnea, poor ventilation, and abnormal oxygenation2

As a result of the body's response to the presence of blood in the pleura, a small hemothorax may lead to a bloody pleural effusion6 When enzymes in the pleural fluid begin to break down blood clots, the protein concentration of the pleural fluid increases, and as a result the osmotic pressure of the pleural cavity increases, causing fluid to flow into the pleural cavity from the surrounding tissues The resulting increase in fluid volume in the pleural cavity interferes with normal breathing and oxygenation, resulting in dypsnea and tachypnea

Diagnosisedit

Play media Hemothorax as seen on ultrasound1 Hemothorax in an animal as seen on plain X ray

Chest radiography is the preferred means of initial diagnosis for hemothorax7 Upright radiography is preferred but supine films may be taken when upright radiography is not feasible due to the clinical situation Tube thoracostomy may be done prior to imaging when patients have sustained blunt or penetrating thoracic trauma and display unstable hemodynamics, have respiratory failure with absent or decreased breath sounds, show tracheal deviation, or have serious penetrating injuries2 In upright radiography, hemothorax is suggested by blunting of the costophrenic angle or partial or complete opacification of the hemithorax, in which the lateral side of the chest appears bright and the lung appears pushed away toward the center; the air-filled lung normally appears as a dark space on radiographic film In the case of a small hemothorax, several hundred milliliters of blood can be hidden by the diaphragm and abdominal viscera In supine patients, signs of hemothorax may also be subtle on radiographic film, because the blood will layer in the pleural space, and can be seen as a haziness in one half of the thorax relative to the other side

Ultrasonography is also used for detection of hemothorax and other pleural effusions, particularly in the critical care and trauma settings, because it provides rapid, reliable results in order to make a diagnosis in an emergency situation7 Computed tomography CT or CAT scans can detect much smaller amounts of fluid than chest radiography, but computed tomography is not a primary method of diagnosis within the trauma setting, due to the time required for imaging, the requirement that a patient remain supine, and the need to transport a critically ill patient to the scanner7

Managementedit

A hemothorax is managed by removing the source of bleeding and by draining the blood already in the thoracic cavity Blood in the cavity can be removed by inserting a drain chest tube in a procedure called a tube thoracostomy Generally, the thoracostomy tube is placed between the ribs in the sixth or seventh intercostal space at the mid-axillary line2 Usually the lung will expand and the bleeding will stop after a chest tube is inserted

The blood in the chest can thicken as the clotting cascade is activated when the blood leaves the blood vessels and comes into contact with the pleural surface, injured lung or chest wall, or with the chest tube As the blood thickens, it can clot in the pleural space leading to a retained hemothorax or within the chest tube, leading to chest tube clogging or occlusion Chest tube clogging or occlusion can lead to worse outcomes as it prevents adequate drainage of the pleural space, contributing to the problem of retained hemothorax In this case, patients can be hypoxic, short of breath, or in some cases, the retained hemothorax can become infected empyema

Retained hemothorax occurs when blood remains in the pleural space, and is a risk factor for the development of complications, including the accumulation of pus in the pleural space and fibrothorax8 It is treated by inserting a second chest tube or by drainage by video-assisted thoracoscopy29 Fibrolytic therapy has also been studied as a treatment

When hemothorax is treated with a chest tube, it is important that it maintain its function so that the blood cannot clot in the chest or the tube If clogging occurs, internal chest tube clearing can be performed using an open or closed technique10 Manual manipulation, which may also be called milking, stripping, or tapping, of chest tubes is commonly performed to maintain an open tube, but no conclusive evidence has demonstrated that any of these techniques are more effective than the others, or that they improve chest tube drainage11 When chest tube clogging does occur, it can result in retained blood syndrome, especially after heart surgery and thoracic surgery

In some cases bleeding continues and surgery is necessary to stop the source of bleeding For example, if the hemothorax was caused by aortic rupture in high energy trauma, surgical intervention is mandatory

Prognosisedit

If left untreated, the condition can progress to a point where the blood accumulation begins to put pressure on the mediastinum and the trachea, effectively limiting the amount that the heart's ventricles are able to fill The condition can cause the trachea to deviate, or move, toward the unaffected side

See alsoedit

  • Cardiac tamponade
  • Hemopneumothorax
  • Pleural effusion
  • Pneumothorax
  • Tension pneumothorax
  • Pulmonary contusion

Referencesedit

  1. ^ a b "UOTW #38 - Ultrasound of the Week" Ultrasound of the Week 18 February 2015 Retrieved 27 May 2017 
  2. ^ a b c d e f Broderick, Stephen R 2013 "Hemothorax" Thoracic Surgery Clinics 23 1: 89–96 ISSN 1547-4127 doi:101016/jthorsurg201210003 
  3. ^ Segura Sampedro, JJ; García Gómez, F; Arroyo Pareja, L; Pardo Prieto, SL; Moreno Mata, N 3 October 2013 "Delayed massive hemothorax due to a diaphragmatic laceration associated with lower rib fractures A penetrating injury in blunt trauma" Cirugia espanola 93: e73–5 PMID 24094593 doi:101016/jciresp201305007 
  4. ^ Misthos, P; Kakaris S; Sepsas E; et al May 2004 "A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma" European Journal of Cardio-thoracic Surgery 25 5: 859–864 PMID 15082295 doi:101016/jejcts200401044 
  5. ^ Rousset, P; Rousset-Jablonski, C; Alifano, M; Mansuet-Lupo, A; Buy, J-N; Revel, M-P 2014 "Thoracic endometriosis syndrome: CT and MRI features" Clinical Radiology 69 3: 323–330 ISSN 0009-9260 doi:101016/jcrad201310014 
  6. ^ Light RW 2010 "Pleural effusion in pulmonary embolism" Semin Respir Crit Care Med 31 6: 716–22 PMID 21213203 doi:101055/s-0030-1269832 
  7. ^ a b c Weldon, Erin; Williams, Jen 2012 "Pleural Disease in the Emergency Department" Emergency Medicine Clinics of North America 30 2: 475–499 ISSN 0733-8627 doi:101016/jemc201110012 
  8. ^ Huggins JT, Sahn SA 2004 "Causes and management of pleural fibrosis" Respirology 9 4: 441–7 PMID 15612954 doi:101111/j1440-1843200400630x 
  9. ^ Billeter, Adrian T; Druen, Devin; Franklin, Glen A; Smith, Jason W; Wrightson, William; Richardson, J David 2013 "Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review" Langenbeck's Archives of Surgery 398 4: 515–523 ISSN 1435-2443 doi:101007/s00423-012-1016-7 
  10. ^ Miller, K S "Chest tubes Indications, technique, management and complications" CHEST Journal 91 2: 258 doi:101378/chest912258 
  11. ^ Wallen, Margaret; Anne Morrison; et al 2008 "Mediastinal chest drain clearance for cardiac surgery" The Cochrane Library 3: 2–27 doi:101002/14651858CD003042pub2 


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