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Abstract
Hemothorax is defined as a bleeding into pleural cavity. Hemothorax is a frequent manifestation of blunt chest
trauma. Some authors suggested a hematocrit value more than 50% for differentiation of a hemothorax from a
sanguineous pleural effusion. Hemothorax is also often associated with penetrating chest injury or chest wall blunt
chest wall trauma with skeletal injury. Much less common, it may be related to pleural diseases, induced iatrogenic
or develop spontaneously. In the vast majority of blunt and penetrating trauma cases, hemothoraces can be
managed by relatively simple means in the course of care.
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amounts of blood in the pleural space may have a similar effect to that A small hemothorax may be overlooked during physical
of chronic subdural hematomas, drawing in fluids over time and examination and even chest radiography.
causing a large effusion with little actual blood content [1,9,11].
The chest wall injuries are subdivided to simple and complex chest
wall injuries.
Late physiologic systemic reaction
A simple chest wall injury consists of less than three single rib
Late physiologic reactions of hemothorax consist of empyema and fractures and superficial soft tissue injuries. This type of injury usually
fibrothorax. can be handled by conservative treatment.
Primary or secondary contamination of hemothorax concludes Fractures of three or more sequential ribs and a flail chest are
empyema. Bronchio-tracheal lesions, esophageal injuries, categorized as complex chest wall injuries and frequently associated
diaphragmatic and subdiaphragmatic injuries, accumulation of fluid in with a significant degree of hemothorax.
the subdiaphragmatic area and postsurgical contamination contribute
to development of posttraumatic empyema (Figure 1). A hemothorax can develop after some interval of trauma. Possible
mechanisms of development of delayed hemothorax are displacement
Fibrothorax results from fibrin deposition in the pleural surfaces of fractured ribs with pulmonary parenchymal laceration, lesion of the
[12]. An undrained pleural fluid regardless of its origin induces an diaphragm or intercostal vessel disruption [15,16].
inflammatory response and leads to inflammatory coating of visceral
and parietal pleura. The chest wall and diaphragm are affected in a
Blunt intrathoracic injuries
similar process, which in total leads to entrapment of the lung. The
entrapment of the lung restricts the ventilatory function and typically Vascular injuries usually lead to large hemothoraces. Laceration of
reduces lung volume [12]. great vessels and heart injuries may result in hemorrhage into the
pleural space and subsequent exsanguination. In rare conditions,
Clinical Manifestations partial tears of vessels create hematomas that may help to arrest the
hemorrhage.
Clinical manifestations of patients with chest trauma are dependent
on mechanism of injury and the organs involved. Patients who suffer Symptoms vary widely from mild to severe, depending on pattern
blunt thoracic trauma are at considerable risk of associated injuries, and location of injury. Respiratory manifestations related to large
deterioration and mortality [13]. In contrast to penetrating thoracic hemothorax as well as dullness to percussion and absent breath sounds
trauma, the biomechanical force required to produce significant blunt are noted as typical signs and symptoms [6,14,16].
thoracic injury often results in multiple injuries including abdominal,
head and extremity injuries [14]. Penetrating trauma
The most common reason for hemothorax after penetration is direct
laceration of arteries of the chest. Other intrathoracic structures,
including heart and pulmonary parenchymal injury should be
considered (Figure 2).
Pulmonary parenchymal injury in penetration of the chest wall is
very common and usually self-limiting, but these injuries usually result
in a hemo-pneumothorax [10,16].
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Minimal collection of blood (defined as <300 ml) in the pleural Video-Assisted Thoracoscopy (VATS)
cavity requires no treatment; the blood is usually resorbed over several
weeks. If the patient is stable and presents with minimal respiratory Video-assisted thoracoscopy (VATS) provides entire vision of the
distress, operative intervention is not required. This group of patients complete pleural cavity with the possibility to correct chest tube –
can be treated by analgesia as needed and observed with repeated chest placement, control of bleeding and removal of retained clot [20,21].
radiographs at 4-6 hours and 24 hours [17]. In case of pulmonary Most authors advise a VATS in the case of hemothorax with more than
parenchymal fistulae after insertion of thoracostomy tube a possibility 300 ml because of more favorable outcomes compared to patients who
of thoracoscopic approach should be evaluated and considered. did not receive a VATS [20-22].
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retained clot with mobilization of the lung for re-expansion. Early answer this question but in a retrospective analysis, VATS was found to
video-assisted thoracoscopy (VATS) has greatly diminished the late be superior to IPFT, both in terms of decreased hospital stay and
complication of hemothorax with positive impact on the length of stay necessity thoracotomy (Figure 4).
in the hospital and survival of patients particularly in elderly.
Published studies revealed clinical outcomes in patients who received Complications
early VATS were more favorable compared to patients who did not
receive early VATS [6,18-23]. Inadequate or incorrect placement of chest tubes leads to
insufficient hemothorax drainage. Bacterial contamination of long-
Video-assisted thoracoscopic surgery (VATS) is believed to be the term retained clot in tube thoracostomy or undrained hemothorax can
best available modality for the management of clotted hemothorax. promote empyema [26]. Fibrothorax develops as a late complication
However, VATS is not routinely available in many centres. One easily due to inflammatory coating of visceral and parietal pleura and
available and effective alternative to VATS is the use of intrapleural reduces the ventilatory function. Decortication of visceral pleura is the
fibrinolysis (IPF) [24-31]. There have not been any prospective trials to therapy of choice to provide lung reexpansion [15,24,25].
Outlook and Discussion hemothorax. Abdominal sonography in case of chest trauma should be
performed routinely [6,15,18-21].
The decision for early removal of retained hemothorax/ blood clots
per VATS greatly reduces late complications such as empyema,
fibrothorax, morbidity and necessity of late secondary thoracotomy. In
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