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Hemothorax Clinical Presentation

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Hemothorax Clinical Presentation

Author: Mary C Mancini, MD, PhD; Chief Editor: Jeffrey C Milliken, MD more... Updated: Jan 29, 2014

History
Trauma or recent surgical intervention is usually self-evident.[24] Occasionally, a hemorrhagic diathesis such as hemorrhagic disease of the newborn or Henoch-Schnlein purpura can lead to spontaneous hemothorax.[12, 11] Internal thoracic artery rupture has been reported in association with Ehlers-Danlos syndrome. A few patients with spontaneous pneumothorax develop hemothorax.[25, 20] Chest pain and dyspnea are common symptoms. Symptoms and physical findings associated with hemothorax in trauma vary widely depending on the amount and rapidity of bleeding, the existence and severity of underlying pulmonary disease, the nature and degree of associated injuries, and the mechanism of injury. Hemothorax in conjunction with pulmonary infarction is usually preceded by clinical findings associated with pulmonary embolism. Catamenial hemothorax is an unusual problem related to thoracic endometriosis. Hemorrhage into the thorax is periodic, coinciding with the patient's menstrual cycle.

Physical Examination
Tachypnea is common; shallow breaths may be noted. Findings include diminished ipsilateral breath sounds and a dull percussion note. If substantial systemic blood loss has occurred, hypotension and tachycardia are present. Respiratory distress reflects both pulmonary compromise and hemorrhagic shock. Children may have traumatic hemothorax without bony fractures of the chest wall.

Blunt chest-wall injuries

Hemothorax is rarely a solitary finding in blunt trauma. Associated chest wall or pulmonary injuries are nearly always present. Simple bony injuries consisting of one or multiple rib fractures are the most common blunt chest injuries. A small hemothorax may be associated with even single rib fractures but often remains unnoticed during the physical examination and even after chest radiography. Such small collections rarely need treatment. Complex chest wall injuries are those in which either 4 or more sequential single rib fractures are present or a flail chest exists. These types of injuries are associated with a significant degree of chest wall damage and often produce large collections of blood within the pleural cavity and substantial respiratory impairment. Pulmonary contusion and pneumothorax are commonly associated injuries. Injuries resulting in laceration of intercostal or internal mammary arteries may produce a hemothorax of significant size and significant hemodynamic compromise. These vessels are the most common source of persistent bleeding from the chest after trauma.
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Hemothorax Clinical Presentation

Delayed hemothorax can occur at some interval after blunt chest trauma. In such cases, the initial evaluation, including chest radiography, reveals findings of rib fractures without any accompanying intrathoracic pathology. However, hours to days later, a hemothorax is seen. The mechanism is believed to be either rupture of a traumaassociated chest wall hematoma into the pleural space or displacement of rib fracture edges with eventual disruption of intercostal vessels during respiratory movement or coughing.

Blunt intrathoracic injuries

Large hemothoraces are usually related to injury of vascular structures. Disruption or laceration of major arterial or venous structures within the chest may result in massive or exsanguinating hemorrhage. Hemodynamic manifestations associated with massive hemothorax are those of hemorrhagic shock. Symptoms can range from mild to profound, depending on the amount and rate of bleeding into the chest cavity and the nature and severity of associated injuries. Because a large collection of blood will compress the ipsilateral lung, related respiratory manifestations include tachypnea and, in some cases, hypoxemia. A variety of physical findings such as bruising, pain, instability or crepitus upon palpation over fractured ribs, chest wall deformity, or paradoxical chest wall movement may lead to the possibility of coexisting hemothorax in cases of blunt chest wall injury. Dullness to percussion over a portion of the affected hemithorax is often noted and is more commonly found over the more dependent areas of the thorax if the patient is upright. Decreased or absent breath sounds upon auscultation are noted over the area of hemothorax.

Penetrating trauma
Hemothorax from penetrating injury is most commonly caused by direct laceration of a blood vessel. While arteries of the chest wall are most commonly the source of hemothorax in penetrating injury, intrathoracic structures, including the heart, should also be considered. Pulmonary parenchymal injury is very common in cases of penetrating injury and usually results in a combination of hemothorax and pneumothorax. Bleeding in these cases is usually self-limited.[26]

Clinical caveats in traumatic hemothorax

Positive physical findings noted by percussion and auscultation are best appreciated in the upright patient and, even then, may be subtle. As much as 400-500 mL of blood may obliterate only the space comprising the costophrenic angle. Many trauma victims are initially examined in the supine position. In such cases, a collection of blood within the pleural space will not occupy the diaphragmatic surface, but will be distributed along the entire posterior aspect of the affected pleural space. Physical examination techniques such as percussion and auscultation may produce equivocal findings even though a substantial collection of blood is present. A hemothorax found in association with a diaphragmatic injury in either penetrating or blunt trauma may actually have its origin from an intra-abdominal source. Blood from injured abdominal organs may traverse a diaphragmatic tear and enter the thoracic cavity. In cases of hemothorax with diaphragmatic injury, the clinician should strongly consider the possibility of intra-abdominal injury.[27]

Nontraumatic hemothorax
Symptoms and physical findings are variable, depending on the underlying pathology. Hemothorax secondary to acute hemorrhage from structures within the chest can produce profound hemodynamic changes and symptoms of shock. Massive hemothorax can result from vascular structures such as a ruptured or leaking thoracic aortic aneurysm or from pulmonary sources such as lobar sequestration or arteriovenous malformation. Disruption of a vascular pleural adhesion unrelated to trauma can produce a significant hemothorax with an associated spontaneous pneumothorax. Occult hemorrhage is most commonly related to metastatic disease or complications of anticoagulation. In these situations, bleeding into the pleural cavity occurs slowly, resulting in subtle or absent changes in hemodynamics.
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Hemothorax Clinical Presentation

When the effusion is large enough to produce symptoms, dyspnea is usually the most prominent complaint. Signs of anemia may also be present. Physical examination reveals findings similar to those for any pleural effusion, with dullness to percussion and decreased breath sounds noted over the area of the effusion.

Contributor Information and Disclosures

Author Mary C Mancini, MD, PhD Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, and Society of Thoracic Surgeons Disclosure: Nothing to disclose. Coauthor(s) Thomas Scanlin, MD Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research, and Society for Pediatric Research Disclosure: Nothing to disclose. Denise Serebrisky, MD Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine; Director, Division of Pulmonary Medicine, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center; Director, Jacobi Asthma and Allergy Center for Children Denise Serebrisky, MD is a member of the following medical societies: American Thoracic Society Disclosure: Nothing to disclose. Specialty Editor Board Charles Callahan, DO Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, and Christian Medical & Dental Society Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Shreekanth V Karwande, MBBS Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association Disclosure: Nothing to disclose. Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
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Disclosure: Nothing to disclose. Chief Editor Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwest Oncology Group, and Western Surgical Association Disclosure: Nothing to disclose. Additional Contributors The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Jane M Eggerstedt, MD, and Allen Fagenholz, MD, to the development and writing of the source articles.

References
1. Tatebe S, Kanazawa H, Yamazaki Y, Aoki E, Sakurai Y. Spontaneous hemopneumothorax. Ann Thorac Surg. Oct 1996;62(4):1011-5. [Medline]. 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. Clark JM, Harryman DT 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am. Jun 1992;74(5):713-25. [Medline]. 4. Johnson EM, Saltzman DA, Suh G, Dahms RA, Leonard AS. Complications and risks of central venous catheter placement in children. Surgery. Nov 1998;124(5):911-6. [Medline]. 5. Waddington MS, Mullins GC. Early complication of pediatric central venous cannulation. Paediatr Anaesth. Nov 2005;15(11):1001-5. [Medline]. 6. Lesher AP, Kratz JM, Smith CD. Removal of embedded central venous catheters. J Pediatr Surg. Jun 2008;43(6):1030-4. [Medline]. 7. Nakayama DK, Ramenofsky ML, Rowe MI. Chest injuries in childhood. Ann Surg. Dec 1989;210(6):770-5. [Medline]. [Full Text]. 8. Sharma OP, Hagler S, Oswanski MF. Prevalence of delayed hemothorax in blunt thoracic trauma. Am Surg. Jun 2005;71(6):481-6. [Medline]. 9. Cottin V, Chinet T, Lavol A, Corre R, Marchand E, Reynaud-Gaubert M, et al. Pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: a series of 126 patients. Medicine (Baltimore). Jan 2007;86(1):1-17. [Medline]. 10. Sinniah D, Nagalingam I. Hemothorax in the newborn. Clin Pediatr (Phila). Feb 1972;11(2):84-5. [Medline]. 11. Huybrechts S, Wojciechowski M, Poot S, Van Reempts P, Ramet J. Hemothorax as presentation of late vitamin-K-deficient bleeding in a 1-month-old infant with homozygous alpha-1-antitrypsin deficiency. Eur J Pediatr. Oct 2007;166(10):1081-2. [Medline]. 12. Hammoudeh M, Qaddoumi NK. Pleural haemorrhage in Henoch Schonlein purpura. Clin Rheumatol. Dec 1993;12(4):538-9. [Medline]. 13. Laberge JM, Puligandla P, Flageole H. Asymptomatic congenital lung malformations. Semin Pediatr Surg. Feb 2005;14(1):16-33. [Medline]. 14. Vaziri M, Mehrazma M. Massive spontaneous hemothorax associated with Von Recklinghausen's disease. Ann Thorac Surg. Oct 2006;82(4):1500-1. [Medline].
emedicine.medscape.com/article/2047916-clinical#showall 4/6

2/8/14

Hemothorax Clinical Presentation

15. Propper RA, Young LW, Wood BP. Hemothorax as a complication of costal cartilaginous exostoses. Pediatr Radiol. Apr 1980;9(3):135-7. [Medline]. 16. Tomares SM, Jabra AA, Conrad CK, Beauchamp N, Phoon CK, Carroll JL. Hemothorax in a child as a result of costal exostosis. Pediatrics . Mar 1994;93(3):523-5. [Medline]. 17. Jin W, Hyun SY, Ryoo E, Lim YS, Kim JK. Costal osteochondroma presenting as haemothorax and diaphragmatic laceration. Pediatr Radiol. Jul 2005;35(7):706-9. [Medline]. 18. Cowles RA, Rowe DH, Arkovitz MS. Hereditary multiple exostoses of the ribs: an unusual cause of hemothorax and pericardial effusion. J Pediatr Surg. Jul 2005;40(7):1197-200. [Medline]. 19. Osawa H, Yoshii S, Takahashi W, Hosaka S, Ishikawa N, Mizutani E, et al. Hemorrhagic shock due to intrathoracic rupture of an osteosarcoma of the rib. Ann Thorac Cardiovasc Surg. Aug 2001;7(4):232-4. [Medline]. 20. Kim ES, Kang JY, Pyo CH, Jeon EY, Lee WB. 12-year experience of spontaneous hemopneumothorax. Ann Thorac Cardiovasc Surg. Jun 2008;14(3):149-53. [Medline]. 21. Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex thoracic injuries. Surg Clin North Am. Aug 1996;76(4):725-48. [Medline]. 22. 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. [Medline]. 23. 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. [Medline]. 24. Bohosiewicz J, Kudela G, Koszutski T. Results of Nuss procedures for the correction of pectus excavatum. Eur J Pediatr Surg. Feb 2005;15(1):6-10. [Medline]. 25. Issaivanan M, Baranwal P, Abrol S, Bajwa G, Baldauf M, Shukla M. Spontaneous hemopneumothorax in children: case report and review of literature. Pediatrics . Oct 2006;118(4):e1268-70. [Medline]. 26. Parry GW, Morgan WE, Salama FD. Management of haemothorax. Ann R Coll Surg Engl. Jul 1996;78(4):325-6. [Medline]. [Full Text]. 27. Miller LA. Chest wall, lung, and pleural space trauma. Radiol Clin North Am. Mar 2006;44(2):213-24, viii. [Medline]. 28. Mandavia DP, Joseph A. Bedside echocardiography in chest trauma. Emerg Med Clin North Am. Aug 2004;22(3):601-19. [Medline]. 29. Trupka A, Waydhas C, Hallfeldt KK, Nast-Kolb D, Pfeifer KJ, Schweiberer L. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma. Sep 1997;43(3):405-11; discussion 411-2. [Medline]. 30. Moore MA, Wallace EC, Westra SJ. The imaging of paediatric thoracic trauma. Pediatr Radiol. May 2009;39(5):485-96. [Medline]. 31. 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. [Medline]. 32. Heniford BT, Carrillo EH, Spain DA, Sosa JL, Fulton RL, Richardson JD. The role of thoracoscopy in the management of retained thoracic collections after trauma. Ann Thorac Surg. Apr 1997;63(4):940-3. [Medline]. 33. Liu DW, Liu HP, Lin PJ, Chang CH. Video-assisted thoracic surgery in treatment of chest trauma. J Trauma. Apr 1997;42(4):670-4. [Medline]. 34. Mancini M, Smith LM, Nein A, Buechter KJ. Early evacuation of clotted blood in hemothorax using thoracoscopy: case reports. J Trauma. Jan 1993;34(1):144-7. [Medline]. 35. Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial. Ann Thorac Surg. Nov 1997;64(5):1396-400; discussion
emedicine.medscape.com/article/2047916-clinical#showall 5/6

2/8/14

Hemothorax Clinical Presentation

1400-1. [Medline]. 36. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. Jul 2004;78(1):282-5; discussion 285-6. [Medline]. 37. Inci I, Ozelik C, Ulk R, Tuna A, Eren N. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax. Chest. Jul 1998;114(1):160-5. [Medline]. 38. Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol. Dec 1 2013;16(6):351-4. [Medline]. 39. Chou YP, Kuo LC, Soo KM, Tarng YW, Chiang HI, Huang FD, et al. The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma. Eur J Cardiothorac Surg. Nov 15 2013;[Medline]. 40. Di Crescenzo V, Laperuta P, Napolitano F, Carlomagno C, Garzi A, Vitale M. Pulmonary sequestration presented as massive left hemothorax and associated with primary lung sarcoma. BMC Surg. Oct 8 2013;13 Suppl 2:S34. [Medline]. [Full Text]. 41. Ernstgrd L, Sjgren B, Gunnare S, Johanson G. Blood and exhaled air can be used for biomonitoring of hydrofluorocarbon exposure. Toxicol Lett. Dec 1 2013;225(1):102-109. [Medline]. 42. May J, Ades A. Porous diaphragm syndrome: haemothorax secondary to haemoperitoneum following laparoscopic hysterectomy. BMJ Case Rep. Dec 5 2013;2013:[Medline]. 43. Ota H, Kawai H, Matsuo T. Video-Assisted Minithoracotomy for Blunt Diaphragmatic Rupture Presenting As a Delayed Hemothorax. Ann Thorac Cardiovasc Surg. Nov 8 2013;[Medline]. 44. Rousset P, Rousset-Jablonski C, Alifano M, Mansuet-Lupo A, Buy JN, Revel MP. Thoracic endometriosis syndrome: CT and MRI features. Clin Radiol. Dec 10 2013;[Medline]. 45. Tantraworasin A, Saeteng S. Massive hemothorax due to intrathoracic extramedullary hematopoiesis in a patient with beta thalassemia hemoglobin E disease. J Med Assoc Thai. Jul 2013;96(7):866-9. [Medline]. Medscape Reference 2011 WebMD, LLC

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