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Hemothorax


Presentation

The following systemwise presentation of signs and symptoms is seen in patients suffering from hemothorax:

  • General appearance: Patients usually presents with anxiety and restlessness due to the profound hypovolemic shock caused by the internal bleeding in the pleural cavity. 
  • Integumentary system: The skin will appear pale, cold and clammy due to the impending hypovolemic shock.
  • Head and neck: The jugular veins may appear bounding and engorged due to pulmonary hypertension.
  • Chest and heart: Chest pain may ensue as the blood collection irritates the pleural nerves. Hypovolemic shock may lead to tachycardia and hypotension in patients with hemothorax. Patients may present with shallow breathing due to the respiratory response of the patient to the space limiting expansion of the blood in the pleura. The region of the hemothorax in the chest may be devoid of breath sounds during auscultation and may be dull upon percussion.
  • Renal: Oliguria may be an early sign of hypovolemic shock.
  • Extremities: Pulses in the extremities will appear thread-like and weak due to the massive exsanguination of blood within the pleural cavity.
  • Neurologic: When patients are brought in the emergency room as unconscious and obtunded, they may be suffering from late symptoms of shock and may require immediate emergency care. 
Dyspnea
  • Patients with hydatid cysts typically present with cough, chest pain, dyspnea, hemoptysis, or allergic reactions. When ruptured, these cysts may cause hemoptysis, dyspnea, and hydatid thorax.[ncbi.nlm.nih.gov]
  • After thoracoscopic surgery, the dyspnea and anemia resolved. On postoperative day 5, the patient left the hospital.[ncbi.nlm.nih.gov]
  • Two days after admission, she complained of dyspnea, and a chest X-ray revealed right pleural effusion. Thoracentesis confirmed the diagnosis of hemothorax.[ncbi.nlm.nih.gov]
  • In this paper, we share a pleural multicystic mesothelial proliferation case arrives the emergency service with sudden chest pain and dyspnea complaint that presented with hemothorax complication.[ncbi.nlm.nih.gov]
  • In this report, we describe a 34-year-old male patient, who presented to emergency service with sudden chest pain and dyspnea.[ncbi.nlm.nih.gov]
Tachypnea
  • She presented with tachypnea, worsening anemia, and oxygen desaturation. Hemothorax was diagnosed based on chest radiography, ultrasonography, and diagnostic thoracic puncture results.[ncbi.nlm.nih.gov]
  • Chest pain, dyspnea , and tachypnea are common presenting features.[en.wikipedia.org]
  • Chest pain Tachypnea Mild to severe dyspnea (difficulty breathing) may be present If respiratory failure results, the patient may appear anxious, restless, possibly stuporous, and cyanotic. Marked blood loss produces hypotension and shock.[med-help.net]
  • […] can result in an even larger pleural effusion Empyema can develop if the blood becomes infected Fibrothorax develops from fibrinous adhesions that lead to entrapment of the underlying lung Clinical Findings Pain related to the chest wall injury Shock Tachypnea[learningradiology.com]
  • Signs and symptoms Tachypnea Dyspnea 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 Possibly subcutaneous[drminkim.com]
Tracheal Deviation
  • 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[en.wikipedia.org]
  • deviation away from pneumothorax - Percussion hyperresonnance - Unilateral absence of breath sounds, hypotension - Non-radiographic diagnosis - large bore IV needle, 2nd ICS mid clavicular line, followed by chest tube in 5th ICS, anterior axillary line[fprmed.com]
  • Complete collapse of the lung may be followed by tracheal deviation and mediastinal shift.[brooksidepress.org]
  • Signs and symptoms Tachypnea Dyspnea 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 Possibly subcutaneous[drminkim.com]
  • The head of the bed reports left tracheal deviation and a right hemithorax absent breath sounds. You quickly perform a needle decompression. As you puncture the pleura to place a chest tube, blood pours onto the floor for what seems like hours.[emdocs.net]
Pleural Disorder
  • Pleural Disorders Your pleura is a large, thin sheet of tissue that wraps around the outside of your lungs and lines the inside of your chest cavity. Between the layers of the pleura is a very thin space.[icdlist.com]
Pallor
  • In the night following admission the patient had acute cardiovascular decompensation with worsening dyspnea, pallor and hypotension.[ncbi.nlm.nih.gov]
  • […] rather than trachea - Gunshot or other wound (hole 2/3 tracheal diameter) /- exit wound - Unequal breathsounds - ABG's: decreased pO2 - Air-tight dressing sealed on 3 sides - Chest tube - Surgery Massive Hemothorax - 1500 cc blood loss in chest cavity - Pallor[fprmed.com]
  • Raynaud's phenomenon Raynaud's phenomenon is episodic vasospasm of the arteries in the extremities, causing pallor followed by cyanosis and/or redness of the fingers and toes (and in some cases the ears and nose).[evidence.nhs.uk]
  • Observe carefully for pallor, blood pressure, and pulse rate, noting the early signs of shock or massive bleeding such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill.[medical-dictionary.thefreedictionary.com]
Amyloidosis
  • In rare instances, extramedullary hematopoiesis, ectopic pregnancy, congenital heart defects, amyloidosis, or parasitic diseases may constitute a source of bleeding.[ncbi.nlm.nih.gov]
Chest Pain
  • In this paper, we share a pleural multicystic mesothelial proliferation case arrives the emergency service with sudden chest pain and dyspnea complaint that presented with hemothorax complication.[ncbi.nlm.nih.gov]
  • A 58-year-old man presented with right-sided chest pain. Radiography and computed tomography showed a pleural effusion in the right chest and a mass in the right hilum. Thoracentesis showed a hemothorax.[ncbi.nlm.nih.gov]
  • In this report, we describe a 34-year-old male patient, who presented to emergency service with sudden chest pain and dyspnea.[ncbi.nlm.nih.gov]
  • Patients with hydatid cysts typically present with cough, chest pain, dyspnea, hemoptysis, or allergic reactions. When ruptured, these cysts may cause hemoptysis, dyspnea, and hydatid thorax.[ncbi.nlm.nih.gov]
  • A 59-year-old woman with a history of von Recklinghausen's disease (VRD) suffered sudden chest pain. Enhanced chest computed tomography showed massive hemothorax, but no evidence of tumors or an obvious bleeding point in the thorax.[ncbi.nlm.nih.gov]
Hypotension
  • In addition, as no obvious hypotension and abdominal discomfort were noted, it was difficult to consider gastrointestinal lesion a possibility.[ncbi.nlm.nih.gov]
  • In the night following admission the patient had acute cardiovascular decompensation with worsening dyspnea, pallor and hypotension.[ncbi.nlm.nih.gov]
  • […] accumulation of air in pleural space - Respiratory distress, tachycardia, distended neck veins, cyanosis, asymmetry of chest wall motion - Tracheal deviation away from pneumothorax - Percussion hyperresonnance - Unilateral absence of breath sounds, hypotension[fprmed.com]
  • If patient vital signs (hypoxia, persistent hypotension), mechanism of injury (penetrating injury), or physical exam (multiple palpable rib fractures, flail segment, significant chest wall ecchymosis or tenderness to palpation) lead you to suspect a hemothorax[emdocs.net]
  • […] trauma that is medial to the nipple line or posterior wounds medial to the scapula Presentation Symptoms patients are usually unresponsive or unconscious Physical exam decreased NOT absent breath sounds in the affected area(s) dullness to percussion hypotension[medbullets.com]
Tachycardia
  • Early symptoms of shock includes tachypnea, tachycardia and decreased pulse pressure. While the blood collects in the pleural space, the lung parenchyma is consequently displaced and unable to expand effectively.[symptoma.com]
  • […] altered mental status - Apnea, cyanosis - Do not wait for ABG's to intubate - definitive airway management - intubate early Tension Pneumothorax - a clinical diagnosis - one-way valve causing accumulation of air in pleural space - Respiratory distress, tachycardia[fprmed.com]
  • […] nipple line or posterior wounds medial to the scapula Presentation Symptoms patients are usually unresponsive or unconscious Physical exam decreased NOT absent breath sounds in the affected area(s) dullness to percussion hypotension collapsed neck veins tachycardia[medbullets.com]
  • Signs and symptoms Tachypnea Dyspnea 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 Possibly subcutaneous[drminkim.com]
  • Some other typical Hemothorax signs and symptoms include Anxiety Restlessness Shortness of breath Tachycardia (rapid heart rate) Cool and clammy skin Low blood pressure Loss of consciousness Fatigue The intensity of Hemothorax symptoms of varies depending[hxbenefit.com]
Thigh Pain
  • A 61-year-old woman presented with thigh pain and gait disturbance due to weakness in her lower right extremity. She was diagnosed with a lumbar disc herniation at L1-2 and the MIS-TLIF procedure was performed.[ncbi.nlm.nih.gov]

Workup

A good clinical history and physical examination may easily seal the diagnosis of hemothorax. However, these laboratory tests and examinations may prove to be helpful in the definitive diagnosis and the management of the hemothorax:

  • Chest radiograph (X-ray): This imaging modality may reveal the exact location of the hemothorax and give the clinician the idea on the extent of the injury to the lungs.
  • Computed tomography (CT-scan):  This confers a more detailed view of the lung parenchyma and the major vessels that might have been severed to cause the blood collection in the pleural space. The CT scan can accurately compute the volume exsanguinous blood in the pleural space.
  • Pleural tap or thoracentesis: The laboratory analysis of the pleural fluid will confirm whether the blood in the pleura is a true hemothorax or just a bloody pleural effusion.

Treatment

Patients presenting in the emergency room with signs of hemothorax should be dealt with promptly. The stabilization of the cardiopulmonary status is given utmost priority followed by the prompt evacuation of the collected blood and pneumothorax in the pleural space. The application of a tube thoracostomy in patients with hemothorax remains to be the primary mode of treatment.

The use of a Video Assisted Thoracoscopic Surgery (VATS) allows the direct removal of clots in the pleura and the precise placement of the chest tubes. VATS may also be used in the direct ligation of chest bleeders to control the progression of hemothorax in some cases [6]. Even in late cases of retained clots, VATS may prove to be useful to evacuate these clots when the patient is already stabilized [7].

In cases of non-traumatic hemothorax, the open thoracotomy approach may prove to be indispensable. This procedure is most useful in the following intrathoracic surgical procedures: stapling of bullous lesions, resection of cavitary diseases and necrotic lung tissue, sequestration of arterio-venous malformation, and repair of aortic aneurysm [8].

Residual pneumothorax is treated by fibrinolysis through the chest tube using streptokinase or urokinase in saline solution [9]. The regular instillation of fibrinolytic compounds in the pleura carries a success rate of up to 92%.

Prognosis

In general, the outcome for traumatic hemothorax is good due to the advances in the health care delivery. Mortality rates in hemothorax varies directly to the severity of the thoracic injury and the important structures involved therein. Retained hemothorax, empyema and fibrothorax is associated with poor morbidity rating. The prompt surgical evacuation of the retained hemothorax is associated with an excellent prognosis.

Complications

The following medical conditions are known to be the common complications of hemothorax:

Etiology

The following clinical conditions may contribute or directly cause hemothorax in patients:

  • Chest trauma
  • Blood dyscrasias or clotting defects
  • Heart or lung surgery (iatrogenic)
  • Pulmonary ischemia or infarction
  • Pulmonary or pleural cancers
  • Vascular tear
  • Tuberculosis

Epidemiology

In the United States, the number of hemothorax cases related to chest trauma approximates 300,000 cases per year [3]. Statistics in a trauma center have confirmed that the relative mortality rate of hemothorax among children reaches 57.1% in blunt chest trauma [4]. In penetrating chest injuries, morbidity was slated at 8.51% complicating to either atelectasis, lung infection, intrathoracic hematoma, wound infection, pneumothorax, or sepsis [5].

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of hemothorax is governed by two basic responses namely: the hemodynamic response, and the respiratory response. Any disruption in the integrity of the chest wall to the lung parenchyma may cause significant bleeding that can fill the pleural space. Given that the pleural cavity can hold up to 4 liters of fluids, an occult exsanguination of blood can cause hypovolemic shock to a patient without eminent bleeding from the outside. Shock can occur if blood loss amounts to more than 30% of the blood volume or approximately 1,500 ml in a 70kg man.

Early symptoms of shock includes tachypnea, tachycardia and decreased pulse pressure. While the blood collects in the pleural space, the lung parenchyma is consequently displaced and unable to expand effectively. The significant impairment in the oxygen exchange in the lungs due to the collection of blood constitutes the respiratory response phase of the hemothorax.

Prevention

Traumatic hemothorax can be prevented by avoiding activities that may lead to blunt injuries to the chest wall. Seat belts must always be in place while driving. Drivers must cautiously drive motorcycles and bicycles to avoid road accidents. Patients diagnosed with tuberculosis must submit to immediate treatment and constant chest X-ray monitoring to prevent spontaneous hemothorax and pneumothorax [10].

Summary

Hemothorax is a clinical condition characterized by the presence of blood between the chest wall and the lung parenchyma (pleural space). The hemorrhage in hemothorax may originate from the lung parenchyma, the great vessels, the heart or the chest wall.

Hemothorax is usually caused by blunt trauma to chest wall but may infrequently be due to diseases conditions, iatrogenic induction or spontaneous [1]. Hemothorax needs immediate evacuation to prevent life threatening complications. To this day, the use of trocar and cannula through an incision in the chest wall to drain the blood and trapped air is still the standard practice [2].

Patient Information

Definition

Hemothorax is defined as a clinical condition characterized by the presence of blood in the pleural space.

Cause

Chest trauma, bleeding defects, chest surgery, pulmonary infarction, cancers and vascular problems are common causes.

Symptoms

Patients will present in anxiety and is usually restless. Signs of shock may ensue with a progressively bleeding hemothorax.

Diagnosis

A thorough clinical history and physical examination. Ancillary procedures like laboratory pleural fluid analysis and imaging techniques may also be implored.

Treatment and follow-up

Tube thoracostomy remains to be the primary mode of treatment, Open thoracotomy may also be an option, the use of VATS for hemothorax evacuation in stabilized patients may also be done, and pleural fibrinolysis may also be done to eliminate the residual pneumothorax

References

Article

  1. Tatebe S, Kanazawa H, Yamazaki Y, Aoki E, Sakurai Y. Spontaneous hemopneumothorax. Ann Thorac Surg. Oct 1996; 62(4):1011-5.
  2. Rusch VW, Ginsberg RJ. Chest wall, pleura, lung and mediastinum. In: Schwartz SI, ed. Principles of Surgery. 7th Ed. New York, NY: McGraw-Hill; 1999:667-790.
  3. Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex thoracic injuries. Surg Clin North Am. Aug 1996; 76(4):725-48.
  4. Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Garcia VF, Bowman LM. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg. Sep 1990; 25(9):961-5; discussion 965-6.
  5. Inci I, Ozcelik C, Nizam O, Eren N, Ozgen G. Penetrating chest injuries in children: a review of 94 cases. J Pediatr Surg. May 1996; 31(5):673-6.
  6. Chang YT, Dai ZK, Kao EL, Chuang HY, Cheng YJ, Chou SH, et al. Early video-assisted thoracic surgery for primary spontaneous hemopneumothorax. World J Surg. Jan 2007; 31(1):19-25.
  7. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. Jul 2004; 78(1):282-5; discussion 285-6.
  8. Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex thoracic injuries. Surg Clin North Am. Aug 1996; 76(4):725-48.
  9. Inci I, Ozçelik C, Ulkü R, Tuna A, Eren N. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax.Chest. Jul 1998; 114(1):160-5.
  10. Issaivanan M, Baranwal P, Abrol S, Bajwa G, Baldauf M, Shukla M. Spontaneous hemopneumothorax in children: case report and review of literature. Pediatrics.

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Last updated: 2017-08-09 17:52