hemotoraks.doc

8/17/2019 hemotoraks.doc

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http://emedicine.medscape.com/article/2047916

Author

Mary C Mancini, M, !h, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery,Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: merican ssociation for!horacic Surgery, merican College of Surgeons, merican Surgical ssociation, Society of !horacicSurgeons, Phi "eta #appa

Disclosure: $othing to disclose%

Coauthor"s#

$homas %canlin, M Chief, Division of Pulmonary Medicine and Cystic &ibrosis Center, Department ofPediatrics, 'utgers 'obert (ood )ohnson Medical School

!homas Scanlin, MD is a member of the following medical societies: merican ssociation for the dvancement of Science, Society for Pediatric 'esearch, merican Society for "iochemistry and Molecular "iology, merican !horacic Society, Society for Pediatric 'esearch


enise %ere&ris'y, M ssociate Professor, Department of Pediatrics, lbert *instein College ofMedicine+ Director, Division of Pulmonary Medicine, Lewis M &raad Department of Pediatrics, )acobiMedical Center+ Director, )acobi sthma and llergy Center for Children

Denise Serebrisy, MD is a member of the following medical societies: merican !horacic Society


%pecialty (ditor )oard

*rancisco $ala+era, !harm, !h d-unct ssistant Professor, University of $ebrasa Medical Center

College of Pharmacy+ *ditor.in.Chief, Medscape Drug 'eference

Disclosure: 'eceived salary from Medscape for employment% for: Medscape%

%hree'anth -arande, M))% Chair, Professor, Department of Surgery, Division of CardiothoracicSurgery, University of Utah School of Medicine and Medical Center

Shreeanth / #arwande, M""S is a member of the following medical societies: merican ssociation for!horacic Surgery, merican College of Chest Physicians, merican College of Surgeons, merican 0eart ssociation, Society of Critical Care Medicine, Society of !horacic Surgeons, (estern !horacic Surgical ssociation


Chie (ditor erey C Milli'en, M Chief, Division of Cardiothoracic Surgery, University of California at 1rvine MedicalCenter+ Clinical Professor, Department of Surgery, University of California, 1rvine, School of Medicine

)effrey C Millien, MD is a member of the following medical societies: lpha 2mega lpha, merican ssociation for !horacic Surgery, merican College of Cardiology, merican College of ChestPhysicians, merican College of Surgeons, merican 0eart ssociation, merican Society for rtificial1nternal 2rgans, California Medical ssociation, 1nternational Society for 0eart and Lung!ransplantation, Phi "eta #appa, Society of !horacic Surgeons, S(23, (estern Surgical ssociation


Additional Contri&utors

Charles Callahan, Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, !ripler rmyMedical Center

http://www.aats.org/http://www.aats.org/http://www.aats.org/http://www.facs.org/http://www.facs.org/http://www.americansurgical.info/http://www.sts.org/http://www.sts.org/http://www.pbk.org/home/index.aspxhttp://www.aaas.org/http://www.aaas.org/http://www.aaas.org/http://www.aps-spr.org/http://www.aps-spr.org/http://www.aps-spr.org/http://www.asbmb.org/http://www.asbmb.org/http://www.asbmb.org/http://www.thoracic.org/http://www.thoracic.org/http://www.thoracic.org/http://www.aps-spr.org/http://www.aps-spr.org/http://www.thoracic.org/http://www.thoracic.org/http://www.aats.org/http://www.aats.org/http://www.aats.org/http://www.aats.org/http://www.chestnet.org/http://www.facs.org/http://www.heart.org/http://www.heart.org/http://www.sccm.org/http://www.sccm.org/http://www.sts.org/http://www.sts.org/http://www.sts.org/http://www.westernthoracic.org/http://www.westernthoracic.org/http://www.alphaomegaalpha.org/http://www.alphaomegaalpha.org/http://www.aats.org/http://www.aats.org/http://www.aats.org/http://www.cardiosource.org/http://www.cardiosource.org/http://www.chestnet.org/http://www.chestnet.org/http://www.chestnet.org/http://www.chestnet.org/http://www.facs.org/http://www.heart.org/http://www.asaio.com/http://www.asaio.com/http://www.asaio.com/http://www.cmanet.org/http://www.ishlt.org/http://www.ishlt.org/http://www.ishlt.org/http://www.pbk.org/home/index.aspxhttp://www.pbk.org/home/index.aspxhttp://www.pbk.org/home/index.aspxhttp://www.sts.org/http://www.swog.org/http://www.westernsurgical.org/http://www.westernsurgical.org/http://www.facs.org/http://www.americansurgical.info/http://www.sts.org/http://www.sts.org/http://www.pbk.org/home/index.aspxhttp://www.aaas.org/http://www.aaas.org/http://www.aps-spr.org/http://www.asbmb.org/http://www.asbmb.org/http://www.thoracic.org/http://www.aps-spr.org/http://www.thoracic.org/http://www.aats.org/http://www.aats.org/http://www.chestnet.org/http://www.facs.org/http://www.heart.org/http://www.heart.org/http://www.sccm.org/http://www.sts.org/http://www.westernthoracic.org/http://www.westernthoracic.org/http://www.alphaomegaalpha.org/http://www.aats.org/http://www.aats.org/http://www.cardiosource.org/http://www.chestnet.org/http://www.chestnet.org/http://www.facs.org/http://www.heart.org/http://www.asaio.com/http://www.asaio.com/http://www.cmanet.org/http://www.ishlt.org/http://www.ishlt.org/http://www.pbk.org/home/index.aspxhttp://www.sts.org/http://www.swog.org/http://www.westernsurgical.org/http://www.aats.org/http://www.aats.org/


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Charles Callahan, D2 is a member of the following medical societies: merican cademy ofPediatrics, merican College of Chest Physicians, merican College of 2steopathicPediatricians, merican !horacic Society, ssociation of Military Surgeons of the US, Christian Medicaland Dental ssociations


Ac'noledements

!he authors and editors of Medscape Drugs 4 Diseases gratefully acnowledge the contributions ofprevious authors )ane M *ggerstedt, MD, and llen &agenhol5, MD, to the development and writing of thesource articles%

"acground

0emothora6 is the presence of blood in the pleural space% !he source of blood may be the chest wall, lungparenchyma, heart, or great vessels% lthough some authors state that a hematocrit value of at least 789 isnecessary to differentiate a hemothora6 from a bloody pleural effusion, most do not agree on any specific

distinction%

0emothora6 is usually a conseuence of blunt or penetrating trauma% Much less commonly, it may be acomplication of disease, may be iatrogenically induced, ;=

Prompt identification and treatment of traumatic hemothora6 is an essential part of the care of the in-uredpatient% !he upright chest radiograph is the ideal primary diagnostic study in the evaluation of hemothora6?see (orup@% 1n cases of hemothora6 unrelated to trauma, a careful investigation for the underlying sourcemust be performed while treatment is provided%

!ube thoracostomy drainage is the primary mode of treatment% /ideo.assisted thoracoscopic surgery?/!S@ may be used% !horacotomy is the procedure of choice for surgical e6ploration of the chest whenmassive hemothora6 or persistent bleeding is present% ?See !reatment%@

3istorical &ac'round0emorrhage from or within the chest has been detailed in numerous medical writings dating bac toancient times% (hile lesser forms of trauma were commonly treated in the ancient physicianAs dailypractice, ma-or in-uries, especially those to the chest, were difficult to treat and often lethal%

"y the


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$ormally, the pleural space, which is between the parietal and visceral pleurae, is only a potential space%"leeding into the pleural space may result from either e6trapleural or intrapleural in-ury%

(trapleural in5ury

!raumatic disruption of the chest wall tissues with violation of the pleural membrane can cause bleedinginto the pleural cavity% !he most liely sources of significant or persistent bleeding from chest wall in-uries

are the intercostal and internal mammary arteries% 1n nontraumatic cases, rare disease processes withinthe chest wall ?eg, bony e6ostoses@ can be responsible%

ntrapleural in5ury

"lunt or penetrating in-ury involving virtually any intrathoracic structure can result in hemothora6% Massivehemothora6 or e6sanguinating hemorrhage may result from in-ury to ma-or arterial or venous structurescontained within the thora6 or from the heart itself% !hese include the aorta and its brachiocephalicbranches, the main or branch pulmonary arteries, the superior vena cava and the brachiocephalic veins,the inferior vena cava, the a5ygos vein, and the ma-or pulmonary veins%

1n-ury to the heart can produce a hemothora6 if a communication e6ists between the pericardium and thepleural space%

1n-ury to the pulmonary parenchyma may cause hemothora6, but it is usually self.limited becausepulmonary vascular pressure is normally low% Pulmonary parenchymal in-ury is usually associated withpneumothora6 and results in limited hemorrhage%

0emothora6 resulting from metastatic malignant disease is usually from tumor implants that seed thepleural surfaces of the thora6%

Diseases of the thoracic aorta and its ma-or branches, such as dissection or aneurysm formation, accountfor a large percentage of specific vascular abnormalities that can cause hemothora6% neurysms of otherintrathoracic arteries such as the internal mammary artery have been described and are possible causes of hemothora6 if rupture occurs%

variety of unusual congenital pulmonary abnormalities, including intralobar and e6tralobar seuestration,;E= hereditary telangiectasia, and congenital arteriovenous malformations, can cause hemothora6%

0emothora6 can result from a pathologic process within the abdomen if blood escaping from the lesion isable to traverse the diaphragm through one of the normal hiatal openings or a congenital or acuiredopening%

Pathophysiology

"leeding into the pleural space can occur with virtually any disruption of the tissues of the chest wall andpleura or the intrathoracic structures% !he physiologic response to the development of a hemothora6 ismanifested in two ma-or areas: hemodynamic and respiratory% !he degree of hemodynamic response isdetermined by the amount and rapidity of blood loss%

3emodynamic response

0emodynamic changes vary, depending on the amount of bleeding and the rapidity of blood loss% "lood

loss of up to 78 mL in a 8.g man should cause no significant hemodynamic change% Loss of 78.


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depending on a number of factors, including organs in-ured, severity of in-ury, and underlying pulmonaryand cardiac reserve%

Dyspnea is a common symptom in cases in which hemothora6 develops in an insidious manner, such asthose secondary to metastatic disease% "lood loss in such cases is not so acute as to produce a visiblehemodynamic response, and dyspnea is often the predominant complaint%

!hysioloic resolution o hemothora

"lood that enters the pleural cavity is e6posed to the motion of the diaphragm, lungs, and otherintrathoracic structures% !his results in some degree of defibrination of the blood so that incomplete clottingoccurs% (ithin several hours of cessation of bleeding, lysis of e6isting clots by pleural en5ymes begins%

Lysis of red blood cells results in a mared increase in the protein concentration of the pleural fluid and anincrease in the osmotic pressure within the pleural cavity% !his elevated intrapleural osmotic pressureproduces an osmotic gradient between the pleural space and the surrounding tissues that favorstransudation of fluid into the pleural space% 1n this way, a small and asymptomatic hemothora6 can progressinto a large and symptomatic bloody pleural effusion%

8ate physioloic seuelae o unresol+ed hemothora

!wo pathologic states are associated with the later stages of hemothora6: empyema and fibrothora6%*mpyema results from bacterial contamination of the retained hemothora6% 1f undetected or improperlytreated, this can lead to bacteremia and septic shoc%

&ibrothora6 results when fibrin deposition develops in an organi5ed hemothora6 and coats both the parietaland visceral pleural surfaces% !his adhesive process traps the lung in position and prevents it frome6panding fully% Persistent atelectasis of portions of the lung and reduced pulmonary function result fromthis process%

*tiology

"y far the most common cause of hemothora6 is trauma% Penetrating in-uries of the lungs, heart, greatvessels, or chest wall are obvious causes of hemothora6+ they may be accidental, deliberate, or iatrogenicin origin%;7= 1n particular, central venous catheter and thoracostomy tube placement are cited as primaryiatrogenic causes%;G, , B=

"lunt chest trauma can occasionally result in hemothora6 by laceration of internal vessels% ;= "ecause of therelatively more elastic chest wall of infants and children, rib fractures may be absent in such cases% ;


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0emothora6 has also been reported in association with costal cartilaginous anomalies% ;>8, >>, >F= 'ib tumorshave rarely been reported in association with hemothora6% 1ntrathoracic rupture of an osteosarcoma of a ribcaused hemorrhagic shoc in a E=

0emothora6 has been noted to complicate a small fraction of spontaneous pneumothora6 cases% lthoughrare, it is more liely to occur in young adolescent males and can be life.threatening secondary to massivebleeding%;>7=

*pidemiology

Juantifying the freuency of hemothora6 in the general population is difficult% very small hemothora6 canbe associated with a single rib fracture and may go undetected or reuire no treatment% "ecause mostma-or hemothoraces are related to trauma, a rough estimate of their occurrence may be gleaned fromtrauma statistics%

ppro6imately G=

1n a FE.month period at a large level.< trauma center, >8BG children younger than


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Physical *6amination

!achypnea is common+ shallow breaths may be noted% &indings include diminished ipsilateral breathsounds and a dull percussion note%

1f substantial systemic blood loss has occurred, hypotension and tachycardia are present% 'espiratorydistress reflects both pulmonary compromise and hemorrhagic shoc% Children may have traumatic

hemothora6 without bony fractures of the chest wall%

)lunt chestall in5uries

0emothora6 is rarely a solitary finding in blunt trauma% ssociated chest wall or pulmonary in-uries arenearly always present%

Simple bony in-uries consisting of one or multiple rib fractures are the most common blunt chest in-uries% small hemothora6 may be associated with even single rib fractures but often remains unnoticed during thephysical e6amination and even after chest radiography% Such small collections rarely need treatment%

Comple6 chest wall in-uries are those in which either E or more seuential single rib fractures are presentor a flail chest e6ists% !hese types of in-uries are associated with a significant degree of chest wall damageand often produce large collections of blood within the pleural cavity and substantial respiratory impairment%

Pulmonary contusion and pneumothora6 are commonly associated in-uries%1n-uries resulting in laceration of intercostal or internal mammary arteries may produce a hemothora6 ofsignificant si5e and significant hemodynamic compromise% !hese vessels are the most common source ofpersistent bleeding from the chest after trauma%

Delayed hemothora6 can occur at some interval after blunt chest trauma% 1n such cases, the initialevaluation, including chest radiography, reveals findings of rib fractures without any accompanyingintrathoracic pathology% 0owever, hours to days later, a hemothora6 is seen% !he mechanism is believed tobe either rupture of a trauma.associated chest wall hematoma into the pleural space or displacement of ribfracture edges with eventual disruption of intercostal vessels during respiratory movement or coughing%

)lunt intrathoracic in5uries

Large hemothoraces are usually related to in-ury of vascular structures% Disruption or laceration of ma-or

arterial or venous structures within the chest may result in massive or e6sanguinating hemorrhage%

0emodynamic manifestations associated with massive hemothora6 are those of hemorrhagic shoc%Symptoms can range from mild to profound, depending on the amount and rate of bleeding into the chestcavity and the nature and severity of associated in-uries%

"ecause a large collection of blood will compress the ipsilateral lung, related respiratory manifestationsinclude tachypnea and, in some cases, hypo6emia%

variety of physical findings such as bruising, pain, instability or crepitus upon palpation over fracturedribs, chest wall deformity, or parado6ical chest wall movement may lead to the possibility of coe6istinghemothora6 in cases of blunt chest wall in-ury%

Dullness to percussion over a portion of the affected hemithora6 is often noted and is more commonly

found over the more dependent areas of the thora6 if the patient is upright% Decreased or absent breathsounds upon auscultation are noted over the area of hemothora6%

!enetratin trauma

0emothora6 from penetrating in-ury is most commonly caused by direct laceration of a blood vessel% (hilearteries of the chest wall are most commonly the source of hemothora6 in penetrating in-ury, intrathoracicstructures, including the heart, should also be considered%

Pulmonary parenchymal in-ury is very common in cases of penetrating in-ury and usually results in acombination of hemothora6 and pneumothora6% "leeding in these cases is usually self.limited% ;F


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Many trauma victims are initially e6amined in the supine position% 1n such cases, a collection of blood withinthe pleural space will not occupy the diaphragmatic surface, but will be distributed along the entire posterior aspect of the affected pleural space% Physical e6amination techniues such as percussion and auscultationmay produce euivocal findings even though a substantial collection of blood is present%

hemothora6 found in association with a diaphragmatic in-ury in either penetrating or blunt trauma mayactually have its origin from an intra.abdominal source% "lood from in-ured abdominal organs may traversea diaphragmatic tear and enter the thoracic cavity% 1n cases of hemothora6 with diaphragmatic in-ury, theclinician should strongly consider the possibility of intra.abdominal in-ury%;F>=

;ontraumatic hemothora

Symptoms and physical findings are variable, depending on the underlying pathology%

0emothora6 secondary to acute hemorrhage from structures within the chest can produce profoundhemodynamic changes and symptoms of shoc% Massive hemothora6 can result from vascular structuressuch as a ruptured or leaing thoracic aortic aneurysm or from pulmonary sources such as lobarseuestration or arteriovenous malformation% Disruption of a vascular pleural adhesion unrelated to traumacan produce a significant hemothora6 with an associated spontaneous pneumothora6%

2ccult hemorrhage is most commonly related to metastatic disease or complications of anticoagulation% 1n

these situations, bleeding into the pleural cavity occurs slowly, resulting in subtle or absent changes inhemodynamics% (hen the effusion is large enough to produce symptoms, dyspnea is usually the mostprominent complaint% Signs of anemia may also be present% Physical e6amination reveals findings similar tothose for any pleural effusion, with dullness to percussion and decreased breath sounds noted over thearea of the effusion%

Differential Diagnoses• *mergent Management of Pleural *ffusion

• 1ntrathoracic malignancy

• Mesothelioma

• Metastatic malignacy

• Pediatric *mpyema

pproach Considerations

Upright chest radiography is the ideal primary diagnostic study in the evaluation of hemothora6% dditionalimaging studies, such as ultrasonography and computed tomography ?C!@, may sometimes be reuired foridentification and uantification of a hemothora6 noted on a plain chest radiograph%

1n some cases of nontraumatic hemothora6, especially those resulting from metastatic pleural implants,patients may present with the finding of a new pleural effusion of unnown etiology, and hemothora6 maynot be identified until the initial diagnostic needle aspiration is performed%

!leural luid hematocrit

Measurement of the hematocrit of pleural fluid is virtually never needed in a patient with a traumatichemothora6, but may be indicated for the analysis of a bloody effusion from a nontraumatic cause% 1n suchcases, a pleural effusion with a hematocrit value more than 789 of that of the circulating hematocrit isconsidered a hemothora6%

Chest 'adiography

Plain radiography of the upright chest may be adeuate to establish diagnosis by showing blunting at thecostophrenic angle or an air.fluid interface if a hemopneumothora6 is present% ?See the image below%@ 1f thepatient cannot be positioned upright, a supine chest radiograph may reveal apical capping of fluid

surrounding the superior pole of the lung% lateral e6trapulmonary density may suggest fluid in the pleuralspace%

http://emedicine.medscape.com/article/807375-overviewhttp://emedicine.medscape.com/article/1001747-overviewhttp://emedicine.medscape.com/article/807375-overviewhttp://emedicine.medscape.com/article/1001747-overview


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Upright posteroanterior chest radiograph of

patient with right hemothora6%

1n the normal unscarred pleural space, a hemothora6 is noted as a meniscus of fluid blunting thecostophrenic angle or diaphragmatic surface and tracing up the pleural margins of the chest wall whenviewed on the upright chest 6.ray film% !his is essentially the same chest radiographic appearance foundwith any pleural effusion%

1n cases in which pleural scarring or symphysis is present, the collection may not be free to occupy themost dependent position within the thora6, but will fill whatever free pleural space is available% !his situationmay not create the classic appearance of a fluid layer on a chest radiograph%

1n the acute trauma setting, the portable supine chest radiograph may be the first and only view availablefrom which to mae definitive decisions regarding therapy% !he presence and si5e of a hemothora6 is muchmore difficult to evaluate on supine films% lthough as much as E88.788 mL of blood is reuired to obliteratethe costophrenic angle on an upright chest radiograph, as much as


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Left hemothora6 in patient with rib fractures%

Ultrasonography

!rauma ultrasonography is used at some trauma centers in the initial evaluation of patients for hemothora6%*ven with the use of chest radiography and helical C!, some in-uries can remain undetected% 1n particular,patients with penetrating chest in-uries may harbor serious cardiac in-ury and a pericardial effusion thatmay be clinically difficult to determine% "edside echocardiography can provide immediate, accurateinformation regarding the pericardium and the need for immediate surgery% 1t can also improve patientoutcome%;FF=

2ne drawbac of ultrasonography for the identification of traumatic hemothora6 is that associated in-uriesreadily seen on chest radiographs in the trauma patient, such as bony in-uries, widened mediastinum, and

pneumothora6, are not readily identifiable on chest ultrasonograms% Ultrasonography more liely plays acomplementary role in specific cases where the chest 6.ray findings of hemothora6 are euivocal%

Computed !omography

!horacic C! ?see the image below@ has a definite role to play in evaluation, particularly if plain radiographyresults are ambiguous or initial therapy is inadeuate%;FE, F7= C! is a highly accurate diagnostic study forpleural fluid or blood and is particularly helpful in locali5ing loculated collections of blood%

http://refimgshow%281%29/


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Contrast.enhanced C! scan of patient with

right hemothora6%

1n the trauma setting, C! does not hold a primary role in the diagnosis of hemothora6 but is complementaryto chest radiography% "ecause many victims of blunt trauma do undergo evaluation with chest C!,abdominal C!, or both, hemothora6 not evident on initial chest radiographs might be identified and treated%

Currently, C! is of greatest value later in the course of management of the chest trauma patient, inparticular for locali5ation and uantification of any retained collections of clot within the pleural space%

lthough multidetector C! allows for the accurate diagnosis of most traumatic in-uries, in pediatric patientsit should be used in selected cases only% 'outine use would result in an unacceptably high radiatione6posure to a large number of patients without proven clinical benefit% ;FG=

pproach Considerations

"lood in the pleural space can be associated with both hemorrhagic shoc and respiratory compromise% 1tmust be effectively evacuated to prevent complications such as fibrothora6 and empyema%

1f chest radiography shows that a hemothora6 is large enough to obscure the costophrenic sulcus or isassociated with a pneumothora6, it should be drained by tube thoracostomy% 1n cases of

hemopneumothora6, placement of two chest tubes may be preferred, with the tube draining thepneumothora6 placed in a more superior and anterior position% ?See the video below%@

1nsertion of chest tube% /ideo courtesy of !herese Canares, MD, and )onathan /alente, MD, 'hode 1sland 0ospital,"rown University%

Surgical e6ploration in cases of traumatic hemothora6 should be performed in the following circumstances:

• *vacuation of more than .E hours

• 'epeated blood transfusion is reuired to maintain hemodynamic stability

!he late seuelae of hemothora6, including residual clot, infected collections, and trapped lung, reuireadditional treatment and, most often, surgical intervention%

'etained clot ?defined as an undrained collection of 788 mL or more as estimated by computedtomography ;C!= or opacification of one third or more of the chest on chest radiography@ is a well.nown

http://refimgshow%283%29/


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seuela after initial tube thoracostomy for hemothora6 and should be evacuated early in the patientAshospital course, if the clinical condition permits% *arly intervention in the case of a retained clot can beperformed with thoracoscopy, provided that the operation is planned within < wee of the bleeding episode%

*mpyema usually develops from superimposed infection in a retained collection of blood% 1t reuiressurgical drainage and, possibly, decortication%

&ibrothora6 is a late uncommon complication that can result from retained hemothora6% !horacotomy anddecortication are reuired for treatment%

$eedle aspiration of a hemothora6 is generally not indicated for definitive treatment% *ven in cases ofnontraumatic hemothora6 that are not identified until diagnostic needle aspiration is performed, completeevacuation of these collections often reuires treatment with tube thoracostomy, similar to hemothoracesresulting from other causes%

*mergency Department Care

1nitial treatment is directed toward cardiopulmonary stabili5ation and evacuation of the pleural bloodcollection% !he patient should be sitting upright unless other in-uries contraindicate this position% dministero6ygen and reassess airway, breathing, and circulation% 2btain an upright chest radiograph as uicly aspossible%

1f the patient is hypotensive, establish a large.bore intravenous line% 1mmediately commence appropriatefluid resuscitation ?eg, with >8 mLIg of lactated 'inger solution@, including blood transfusion as necessary%

*valuate for the possibility of tension pneumothora6% $eedle decompression of a tension pneumothora6may be necessary%

!he need for a chest tube in an asymptomatic patient is unclear, but if the patient has any respiratorydistress, perform thoracostomy% 1f a conventional chest tube is not removing the blood collection, furthersteps may be necessary% Conventional treatment involves placement of a second thoracostomy tube%0owever, in many patients, this therapy is ineffective, necessitating further intervention%

!ube !horacostomy

!ube thoracostomy drainage is the primary mode of treatment for hemothora6% 1n cases of trauma, patient

assessment should be performed using the advanced trauma life support ?!LS@ protocol before tubethoracostomy for hemothora6%

!his procedure is relatively contraindicated when significant pleural adhesions are nown to be present%1ncomplete drainage or inability to effectively access the area is liely% lso, blunt division of pleuraladhesions may cause additional bleeding and result in lung laceration% 1f evacuation of such collections ismandated clinically, thoracotomy with division of adhesions under direct vision is the safer approach%

rainae in patients ith coaulopathy

lthough not contraindicated, drainage of hemothora6 or any pleural effusion in an individual with acoagulopathy should be performed with great care% !his group includes patients receiving anticoagulationtherapy and those with significant liver disease or inherited coagulation factor deficiencies% $ormali5ation of coagulation function by cessation of anticoagulants or correction of factor deficiencies using appropriate

blood products, if necessary, should be initiated before a drainage procedure, if possible%

$eedle aspiration should not be performed if clotting deficiencies are present% 'ather, tube thoracostomyshould be used, with the ability to visuali5e and control any chest wall bleeding that is encountered% 1fnecessary, in individuals reuiring long.term anticoagulant therapy, this medication can be resumed B.hours after the thoracostomy has been completed%

(uipment

tube thoracostomy tray or it should be readily available in every hospital emergency department% 1n adultpatients, large.bore chest tubes ?usually FG.E> &rench@ should be used to achieve adeuate drainage%Smaller.caliber tubes are more liely to occlude% 1n pediatric patients, chest tube si5e varies with the si5e of the child% 1n patients older than years, the chest tube si5e used is usually the same as that for adults% 1nsmaller children, a >E. to FE.&rench chest tube should be used, depending on the si5e of the child%

!rocedure


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lthough tube thoracostomy may be performed rapidly in some circumstances, sterile techniue shouldalways be employed% !he insertion site should also be infiltrated with a local anesthetic%

2n insertion, the thoracotomy tube is directed toward the costophrenic angle% ttention should be given tothe location of insertion on the chest wall and the intrathoracic position of the tube as seen on the chestradiograph% &or ma6imum drainage, thoracostomy tube placement for hemothora6 should ideally be in thesi6th or seventh intercostal space at the posterior a6illary line% 1n the supine trauma victim, a common errorin chest tube insertion is placement too anteriorly and superiorly, maing complete drainage very unliely%

*olloup

fter tube thoracostomy is performed, a repeat chest radiograph should always be obtained immediately%!his helps identify chest tube position, helps determine completeness of the hemothora6 evacuation, andmay reveal other intrathoracic pathology previously obscured by the hemothora6%

chest tube is usually put to water seal after the lung is fully ree6panded on radiography, fluid drainage isless than 78 mL in >E hours, and no significant residual air lea is present% Situations may e6ist when achest tube must be clamped% (hen no recurrence of air or fluid collection occurs on follow.up radiographicstudies, the tube is then usually removed% postremoval radiograph should be obtained%

1f drainage is incomplete as visuali5ed on the postthoracostomy chest radiograph, placement of a second

drainage tube should be considered% Preferably, a video.assisted thoracic surgery ?/!S@ procedureshould be undertaen to evacuate the pleural space%

s many as 8.B89 of individuals who sustain traumatic hemothora6 are successfully treated by tubethoracostomy drainage and reuire no further therapy% 2btain at least one or two additional chestradiographs over a period of wees to confirm that no further intrathoracic collections or abnormalitiesare present%

!he need for further follow.up chest radiographs may be dictated by the presence of other intrathoracicpathology and by additional symptoms and physical findings% &urther treatment or follow.up is determinedby the nature of any other in-uries%

/ideo.ssisted !horacoscopic Surgery

/ideo.assisted thoracoscopic surgery ?/!S@ is an alternative treatment that permits direct removal of clotand precise placement of chest tubes% Several centers have used this modality successfully to help identifyand control the source of bleeding in a number of cases% ;F= 1n comparison with thoracostomy, /!S isassociated with fewer postoperative complications and shorter hospital stays%

!horacotomy

!horacotomy is the procedure of choice for surgical e6ploration of the chest when massive hemothora6 orpersistent bleeding is present% t the time of surgical e6ploration, the source of bleeding is controlled andthe hemothora6 is evacuated%

Surgical e6ploration of the chest may be reuired later in the course of the patient with hemothora6 forevacuation of retained clot, drainage of empyema, or decortication% Cases with retained clot can often betreated successfully with a /!S procedure, especially if this is accomplished within days of initialdrainage of the hemothora6, but thoracotomy is usually reuired for adeuate empyema drainage or

decortication%

1n nontraumatic cases of hemothora6 resulting from surgically correctable intrathoracic pathology,correction of the underlying disease process and evacuation of the hemothora6 should be undertaen% !hismay include stapling or resection of bullous disease, resection of cavitary disease, resection of necroticlung tissue, seuestration of arteriovenous malformations, or resection or repair of vascular abnormalitiessuch as aortic aneurysms% ;>G=

!he decision to perform surgical e6ploration in cases of hemothora6 from acute trauma is based on anumber of factors, including the volume and persistence of blood loss, the overall hemodynamic state ofthe patient, and the amount of blood replacement reuired% ?See pproach Considerations %@

/olume resuscitation should be performed according to !LS protocol and should be continued en route tothe operating room% Some forethought must be given to the availability of blood products if needed rapidly%

nesthesia should be started rapidly, and all maneuvers should be employed to prevent aspiration% lthough a double.lumen endotracheal tube is a very useful lu6ury to have in thoracic surgical cases, it is


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only absolutely necessary in a few cases and should not be considered unless it can be placed withoutdelaying the operative procedure% Standard endotracheal intubation is adeuate in most cases%

t least two secure large.bore intravenous lines must be established before surgery so that fluids andblood products can be administered rapidly if needed% n arterial line should be placed, but centralintravenous access is not an absolute necessity, and surgery should not be delayed for such procedures%Pulse o6imetry and the end.tidal carbon dio6ide value should be monitored during the procedure%

1f stability of the spine or other seletal structures has not been fully determined before e6ploratorythoracotomy, every effort must be made to maintain proper support and stabili5ation of these structureswhen positioning the patient for thoracotomy%

1n hemodynamically unstable patients, volume resuscitation must be maintained during the administrationof any anesthetic agents because further instability and hypotension may ensue with anesthesia induction%

dose of intravenous antibiotics should be administered before emergency e6ploration% 3enerally, abroad.spectrum cephalosporin is advisable% 1f thoracoabdominal in-ury is present and bowel in-ury isconsidered, coverage for gastrointestinal tract organisms should be added%

Conservation of patient body temperature in trauma surgery is e6tremely important% variety of surface.warming devices are available and can be used to cover the patient, leaving only the operative field open%

(armers should also be used for intravenous crystalloid and blood products% 'aising the ambienttemperature in the operating room may be necessary% Maintenance of body temperature is e6tremelyimportant to prevent complications such as coagulopathy and cardiac arrhythmias%

ntraoperati+e details

1n the ma-ority of trauma cases necessitating chest e6ploration, the bleeding source is from the chest wall,most commonly intercostal or internal mammary arteries% 2nce identified, these can be easily controlledwith suture ligatures in most cases% fter control of obvious bleeding and evacuation of clot and blood, arapid but thorough e6ploration of the entire chest cavity should be performed%

Unstable rib fractures found at the time of surgery may reuire some debridement of sharp rib edges toprevent further in-ury to the lung or ad-acent chest wall structures% t some centers, flail segments ore6tensive rib fractures are stabili5ed with wires or other types of support in an attempt to improve

postoperative chest wall mechanics%

thoracic surgeon should be present or immediately available at the time of emergency thoracice6ploration because control of bleeding from difficult areas such as the hilum of the lung, the heart, or thegreat vessels may reuire a surgeon with e6pertise in that field%

Patients with in-uries between the level of the nipples and the umbilicus may have in-uries in both the chestand abdomen% 1f surgical e6ploration is mandated, proper positioning, prepping, and draping of thesepatients is wise so that access to both cavities is possible%

(ith the patient prepared in this manner, an unanticipated abdominal bleeding source beneath a ruptureddiaphragm found at the time of chest e6ploration for hemothora6 can be addressed more easily% !he chestcan be rapidly e6plored to help rule out additional intrathoracic sources, and attention can then be uiclyturned to abdominal e6ploration% !his preparation also allows ready thoracic access for clamping the

thoracic aorta if hemodynamic instability arises from massive or uncontrolled hemorrhage at the time ofabdominal e6ploration%

Diaphragmatic in-uries may be closed from either the thora6 or the abdomen% 1n the acute trauma setting, itis usually closed from the abdomen%

deuate drainage of the chest after control of bleeding is very important% "ecause chest drainage tubesare placed under direct vision, the complication of retained hemothora6 should occur with e6tremeinfreuency% minimum of two large.bore chest tubes should be used, with one positioned posteriorly andthe other positioned anteriorly% Some surgeons prefer the addition of a right.angled chest tube positionedover the diaphragm%

!ostoperati+e details

/entilator management should progress according to the individual status of the patient% 1n cases where no

other significant in-ury or disease process is present, weaning and e6tubation may proceed in a routine


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fashion% 1n more critically ill patients such as those with severe chest wall in-uries or those reuiringmassive transfusion, ventilator management must be tailored to the condition of the patient%

fter e6tubation, pulmonary toilet and adeuate pain control are critical in preventing pulmonarycomplications such as atelectasis and pneumonia%

Chest tubes are maintained on underwater seal suction, and the volume of drainage and air lea are noted

and recorded daily% 1f pulmonary in-ury is found or resection of lung tissue is reuired at the time of surgery,chest tubes are not removed until any air lea has disappeared and the lung is fully e6panded as viewed onthe chest radiograph% Drainage should be less than E hours before chest tube removal%

ntibiotic coverage begun preoperatively should be discontinued after EB hours unless a definite reasone6ists for continuance%

/entilator management should progress according to the individual status of the patient% 1n cases in whichno other significant in-ury or disease process is present, weaning and e6tubation may proceed in a routinefashion% 1n more critically ill patients, such as those with severe chest wall in-uries or those reuiringmassive transfusion, ventilator management must be tailored to the condition of the patient% ftere6tubation, pulmonary toilet and adeuate pain control are critical in preventing pulmonary complicationssuch as atelectasis and pneumonia%

Management of 'etained Clot ppro6imately >89 of patients who initially have tube thoracostomy for drainage of hemothora6 will havesome amount of residual clot in the thoracic cavity% Some controversy e6ists regarding the management ofretained clot after tube thoracostomy% 2pinions range from conservative watchfulness to additional chesttube placement to surgical evacuation% Current opinion seems to favor some form of clot evacuation%

Many trauma centers are moving away from additional tube thoracostomy and, instead, advocating anearly /!S procedure% !his is usually performed within .B days of the initial in-ury and, in some centers, isperformed within EB.> hours if a retained clot is identified within the thora6% ;FB, F, E8, E=

&or /!S evacuation of the hemothora6 or retained clot, one.lung ventilation is not reuired% single.lumentube can be used with directions to the anesthesiologist to decrease tidal volume or intermittently hold

ventilation during the procedure% 1f cardiac, great vessel, or tracheobronchial in-ury is found, conversion tothoracotomy can be performed e6peditiously%

!he decision to perform early evacuation of retained hemothora6 with /!S technology is liely to greatlydiminish the number of patients who develop the seuelae of empyema and fibrothora6% lthough it addsan operative procedure to the patientAs management, this approach provides definitive treatment whileavoiding the morbidity of a formal thoracotomy, and it shortens the total hospital stay when compared withmore conservative management methods%

Patients undergoing surgical intervention for retained hemothora6 in either an acute or late setting aremonitored in the same fashion as any patient who has undergone /!S or thoracotomy% 3enerally, thechest tube is removed when drainage is less than 78,888 1U of streptoinase or


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not liely to become routine, because of the length of in.hospital time reuired for complete treatment andthe ris of untoward effects%

Complications

'ee6pansion pulmonary edema after evacuation of retained hemothora6 is a rare reported complication% ssociated factors in the development of this problem appear to be hypovolemia and the administration of

large amounts of blood products and other volume e6panders in the perioperative period%

*mpyema can develop if a retained clot becomes secondarily infected% !his can occur from associatedpulmonary in-uries or from e6ternal sources such as the penetrating ob-ect or missile that caused theoriginal in-ury or the presence of a long.standing clotted thoracostomy tube%

&ibrothora6 and trapped lung develop if fibrin deposition occurs within a clotted hemothora6% !his can leadto persistent atelectasis and a reduction of pulmonary function% decortication procedure may benecessary to permit lung e6pansion and reduce the ris of empyema%

Medication Summary

$o data support routine antibiotic coverage of chest tubes in patients with hemothora6% Pain control mayreuire intravenous opioid analgesic agents, intracostal nerve blocs around the chest tube site, or both%Low suction should be used on the chest tube%

88% !atebe S, #ana5awa 0, Kama5ai K, oi *, Saurai K% Spontaneous hemopneumothora6% AnnThorac Surg % ?E@:


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FE% !rupa , (aydhas C, 0allfeldt ##, $ast.#olb D, Pfeifer #), Schweiberer L% /alue of thoraciccomputed tomography in the first assessment of severely in-ured patients with blunt chest trauma:results of a prospective study% J Trauma%

hemotoraks.doc

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