HEMOTHORAX

~ Шрейаси Павар
503
 INTRODUCTION

• The term hemothorax can be defined as the entry of

pleural fluid and blood into the pleural cavity.
• CRITERIA - It needs to be pleural fluid with a hematocrit
of 25% -50% of the patient’s blood to be diagnosed as a
hemothorax.
 ETIOLOGY

• The primary cause of haemothorax is sharp or blunt trauma

to the chest.
• Iatrogenic or spontaneous haemothorax occur less
frequently.
• Iatrogenic haemothorax most likely occurs as a
complication of cardiopulmonary surgery, placement of
subclavian or jugular catheters, or lung and pleural
biopsies.
• Spontaneous haemothorax is generally caused by rupture of
pleural adhesions, neoplasm, pleural metastasis, and as a
complication of anticoagulant therapy for pulmonary
embolisms.
• Less common causes include iatrogenic (e,.g. post-lung biopsies), malignancy (e.g.
pleural metastasis), or disorders of blood vessels (e.g. Rendu-Osler-Weber
Syndrome) or clotting (e.g. Haemophilia A).
• Warfarin, a commonly used oral anticoagulant, is associated with several adverse
drug reactions, principally bleeding. Of all hemorrhagic complications from
warfarin therapy, thoracic hemorrhage accounts for only 3% and is usually related to
trauma.
 PATHOPHYSIOLOGY

• There are two layers of pleura. One of which covers the lung
surface (visceral pleura) and the other the inside of the chest wall
(parietal pleura). (For more detailed information on lung anatomy).
These layers of pleura adhere to each other to keep the lung from
collapsing, even with the expiration of air from the lung.
• If air or fluid enters the pleural cavity in between these layers of
pleura, it causes the lung to collapse due to its elastic recoil. If it is
only air entering the pleural cavity it causes a pneumothorax. If it
is fluid or blood entering the pleural cavity it could cause a pleural
effusion or Hemothorax.
The accumulation of pleural blood forms a stable
clot
• overall ventilation & oxygenation becomes
impairecavity. hanical compression of the lung
parenchyma
• mediastinal shift
• flattening of the hemidiaphragm
• Over time, the clot is partially-absorbed, leaving
behind loculated fluid and fibrinous septations
• macro-fibrin deposition begins to provide a
structural framework
• this “peel” slowly contracts to entrap the
underlying lung
• The membrane continues to thicken by
progressive deposition and organization of the
coagulum within the cavity
 CLINICAL FEATURES

Patients will commonly present following trauma with chest pain and
worsening dyspnoea. In large cases, patients can be hypoxic and hypotensive.
On examination, there will be a dullness to percussion on the affected side and
reduced breath sounds on auscultation. In severe cases, there is reduced chest
expansion on the affected side and potential tracheal deviation to the
contralateral side.
• Blunt injury may also cause bruising to the chest wall and crepitus (surgical
emphysema). A flail segment may be evident in those who have sustained
sizeable trauma.
Shortness of breath.
Rapid, shallow breathing.
Chest pain.
Low blood pressure (shock)
• Pale, cool and clammy skin.
• Cold sweats.
• Rapid heart rate.
• Restlessness.
• Anxiety.
• Respiratory Distress
• Tachypnea
• Decreased or absent breath sounds
• Chest wall asymmetry
• Tracheal Deviation
CLINICAL FEATURES
STAGES
 INVESTIGATIONS

Patients with suspected haemothorax should be approached in an A to E

manner, following ATLS guidelines, with concurrent investigations and
interventions as required. Routine bloods, including FBC, U&Es, and
clotting, should be performed.
Suspected cases should have an erect plain film chest radiograph
performed, in both AP and lateral views. This will show blunting of the
costophrenic angle, and larger haemothorax will demonstrate a meniscus
level +/- a contralateral mediastinal shift
• As most cases are traumatic in nature, often patients will undergo CT
imaging for the diagnosis to be confirmed, which will better
characterise the size of the haemothorax and will importantly assess for
other concurrent injuries.
 DIFFERENTIAL DIAGNOSIS

Visceral injuries - Skeletal Injuries -

Ruptured diaphragm Flail chest

Pulmonary contusion Rib fracture

Pneumothorax Sternoclavicular fractures or dislocations

Hemothorax Scapular fracture

Tracheobronchial injuries Clavicular fracture or dislocation

Esophageal injury • Vertebral or spinal injury

• Pneumomediastinum

Cardiovascular injuries

Aortic rupture

Caval injury

Pericardial effusion/tamponade

Subclavian artery injury

Intercostal artery injury

Commotio cordis
 COMPLICATIONS

Collapsed lung, or pneumothorax, leading to respiratory failure (inability to

breathe properly)
Fibrosis or scarring of the pleural membranes and underlying lung tissue
Infection of the pleural fluid (empyema)
Shock and death in severe circumstances
Lung entrapment
Impaired pulmonary function
Retained clot
Chronic fibrothorax
Extended hospitalization
Atelectasis
• Pneumonia
 PREVENTION

Depending on the cause, a hemothorax may or may not be preventable.

Since trauma is the most common cause, taking safety measures when
doing activities may decrease the chance of trauma to the chest.
Examples include wearing a seat belt when driving or wearing chest
protection garments if involved in contact sports.
• Additionally, a hemothorax may occur from lung cancer, and it’s
known that smoking tobacco is the leading cause of lung cancer.8
Smoking cessation can decrease the risk of developing lung cancer
which reduces the chance of complications of lung cancer, such as a
hemothorax.
 MANAGEMENT

Chest tube drainage – THORACOSTOMY

• In most cases, chest tube drainage by means of a large
calibre (≥28 French) tube is an adequate initial approach
unless an aortic dissection or rupture is suspected. After
the tube thoracostomy is performed, a chest radiograph
should always be repeated in order to identify the position
of the chest tube, to reveal other intrathoracic pathology
and to confirm whether the collection of blood within the
pleural cavity has been fully drained.
 VIDEO-ASSISTED THORACOSCOPIC
SURGERY

VATS can provide excellent visualization of the

pleural cavity that is more useful for evacuating
the hemothorax than using additional tube
thoracostomies. The wounds caused by VATS are
much smaller than those caused by a
thoracotomy.. Therefore, this procedure may
prevent further injury to the chest wall.
• The main functions of VATS include
evaluation and control of continued bleeding,
early evacuation of a retained hemothorax,
evacuation and decortication of posttraumatic
empyemas, limited invasive treatment of
suspected diaphragmatic injuries, treatment of
persistent air leaks, and evaluation of
mediastinal injuries.
 THORACOTOMY

• Thoracotomy is indicated when total chest tube

output exceeds 1500 mL within 24 hours,
regardless of injury mechanism. THE
INDICATIONS for thoracotomy after
traumatic injury typically include shock, arrest
at presentation, diagnosis of specific injuries
(such as blunt aortic injury), or ongoing
thoracic hemorrhage
 INTRAPLEURAL FIBRINOLYTIC
THERAPY

• Intrapleural fibrinolytic therapy (IPFT) can be applied in an attempt to

evacuate residual blood clots and breakdown adhesions when initial
tube thoracostomy drainage is inadequate. Retention of blood in the
pleural cavity may lead to lung entrapment, chronic fibrothorax,
impaired lung function and infection.
• Duration of treatment with IPFT vary between 2 and 9 days for
streptokinase and 2–15 days for urokinase.
• In most cases, treatment with IPFT leads to complete resolution of
radiographic abnormalities, through evacuation of blood clots and
loculated effusions. Less than 10% of cases need a more aggressive
treatment by means of surgical decortication.
• If chest tube drainage and IPFT does not lead to sufficient resolution
of the retained clots, surgical intervention should be considered.
 PROPHYLACTIC ANTIBIOTICS

• Antibiotic treatment following haemothorax reduces the rate of

infectious complications.The guidelines recommend the use of first
generation cephalosporins during the first 24 h in patients treated with
chest tube drainage for haemothorax. When empyema occurs during
chest tube drainage, antibiotic treatment should be directed to
Staphylococcus aureus and Streptococcus species.
• prophylactic use of antibiotics during at least 24 h after the start of chest
tube drainage for haemothorax, reduced the incidence of pneumonia
from 14.8% to 4.1%.9 The incidence of empyema decreased from 8.7%
to 0.8%.
• In general, 24 h of antibiotic treatment is advised in traumatic
haemothorax.
TREATMENT ALGORITHM
 PROGNOSIS

The outcome of a hemothorax is determined by both the extent of the

bleeding, and the underlying cause.1
For people who sustain a hemothorax as a result of chest trauma, the
overall prognosis is actually quite good, and excellent if the hemothorax
can be adequately treated.
Prognosis may also be good when the hemothorax occurs as a
complication of a biopsy or chest surgery.
• When a hemothorax occurs in the presence of cancer (due to growth of
the tumor through the lung lining) or a pulmonary infarct, however, the
prognosis is more guarded.
 CONCLUSION

• Hemothorax is a relatively common problem, most often resulting from

injury to intrathoracic structures of the chest wall. Non-traumatic
haemothorax can be a complication due to various causes. Rapid
identification of the cause and initiation of treatment is essential. In
haemodynamically unstable patients tube drainage and surgery is
indicated. In haemodynamically stable patients evacuation of blood
from the pleural cavity by chest tube with or without IPFT should be
performed. If this treatment is not successful, surgery is indicated in
order to prevent long-term complications and impaired pulmonary
function.
 REFERENCES

• https://www.sciencedirect.com/science/article/pii/S0954611110003513
• https://www.verywellhealth.com/hemothorax-meaning-causes-and-prognosis-2
249109#:~:text=For%20people%20who%20sustain%20a,a%20biopsy%20or%
20chest%20surgery
.
• https://pubmed.ncbi.nlm.nih.gov/9674464/
• https://pubmed.ncbi.nlm.nih.gov/20817498/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633323/