Hemothorax

Hemothorax is defined as a collection of f blood within the pleural space

Types

1. Traumatic

• It can be due to blunt or penetrating chest trauma
• A massive hemothorax is due to aortic injury, myocardial rupture, and injuries to hilar structures.
• Other causes are injury to the lung parenchyma and intercostal or mammary blood vessels.

2. Nontraumatic

Causes include;

• Spontaneous pneumothorax- most common
• Malignancy
• Vascular disease
• Endometriosis
• Coagulation disorders

Clinical features

Nontraumatic- signs and symptoms of the underlying disorder. Tachycardia and hypotension, if significant.

Traumatic-

• Dyspnoea, chest pain, hemorrhagic shock, flat chest veins, reduced breath sounds, dullness on percussion, decreased tactile fremitus, crepitus on palpation, reduced chest expansion

Investigations

1. Chest Xray-
2. Opacification
3. Blunting of costophrenic angle
4. Air fluid level
5. Tracheal deviation in a massive hemothorax

* A volume of 300ml is required for hemothorax to manifest on an upright chest Xray

2. Ultrasound-

• Commonly used in the FAST protocol
• Smaller volumes can be detected
• Hyperechogenic signal in the costodiaphragmatic recess

* Features of underlying disease in nontraumatic hemothorax

3. Chest CT – can identify an underlying malignancy

4. Chest CTA- can identify the source of bleeding

5. Pleural fluid analysis

6. Complete blood count

Management

-Stabilize the patient first

-A massive hemothorax is a life-threatening condition

-Tube thoracostomy with a size 28 to 32 french chest tube.

-Immediate drainage of ≥20 ml/kg ( approximately 1500ml ) is an indication for surgical thoracotomy. Other indications for thoracotomy;

• Shock
• Persistent, substantial bleeding, >3ml/kg/hr

-IV fluid resuscitation

-Closely monitor vital signs

-Confirm or rule out other life-threatening conditions. These are considered when determining the need for thoracotomy.

-Pneumohemothorax- drain with a tube thoracostomy.

-Small collections (<300ml) can be treated with expectant management or needle aspiration and drainage.

-Identify and treat the underlying cause for nontraumatic causes

Complications

• Trapped lung
• Pleural empyema
• Fibrothorax