Hemotorax

Hemothorax is the presence of blood in the pleural space, specifically

when the hematocrit of the pleural fluid is greater than or equal to 50%
of that of the peripheral blood.
Etiology
• Hemothorax is a frequent manifestation of traumatic injury (blunt or
penetrating) to thoracic structures.
• Most cases of hemothorax arise from blunt mechanism with an
overall mortality of 9.4%.
• Non-traumatic causes are less common. Examples include iatrogenic,
lung sequestration, vascular, neoplasia, coagulopathies, and
infectious processes.
Traumatic Hemothorax
• Blood may enter the pleural space from injury to the chest wall,
diaphragm, lung, blood vessels, or mediastinum.
• On entering the pleural space, the blood coagulates rapidly, but,
presumably as a result of the physical agitation produced by
movement of the heart and lungs, the clot may be defibrinated,
rendering it liquid and unable to clot again.
• Loculation may develop early in the course of hemothorax.
Mechanism of Injury
The mechanisms of action that were predictive of significant thoracic
injury are
• motor vehicle accident greater than 35 mph,
• fall from more than 15 feet,
• pedestrian ejection of more than 10 feet,
• trauma with depressed level of consciousness.
Anamnesis
Important history components include
• chest pain,
• dyspnea,
• mechanism of injury (fall, direction, and speed),
• drug/alcohol use,
• comorbidities,
• surgical history,
• anticoagulation/antiplatelet therapies.
 Physical Examination
Clinical findings of hemothorax are broad and may overlap with pneumothorax; these include
• respiratory distress,
• tachypnea,
• decreased or absent breath sounds,
• dullness to percussion,
• chest wall asymmetry,
• tracheal deviation,
• hypoxia,
• narrow pulse pressure,
• hypotension.
• Inspect the chest wall for signs of contusion, abrasions, "seat belt sign," penetrating injury,
paradoxical movement ("flail chest”), ecchymosis, deformities, crepitus, and point
tenderness.
• Distended neck veins are concerning for pneumothorax or pericardial tamponade but might
be absent in the setting of hypovolemia.
• Increased respiratory rate, effort, and use of accessory muscles may be signs of impending
respiratory failure.
Imaging
• Chest x-ray continues to be the initial diagnostic tool in the screening of traumatic
thoracic injuries.
• Chest x-ray reveals the presence of pleural fluid but does not prove it to be blood;
a preexisting pleural effusion would have an identical radiographic appearance.
• The CT scan is more sensitive than the chest radiograph in detecting
hemothoraces.
• CT scan of the chest is indicated for its ability to identify hemothorax, as well
as pneumothoraces, lung contusion, and bone fractures.
• Studies show that ultrasound is a superior diagnostic tool in detection of
traumatic thoracic injuries (e.g., pneumothorax and hemothorax)
• Ultrasound can detect as little as 20 ml of pleural fluid compared to 175 ml with
radiography, and is 100% sensitive for detecting effusions greater than 100 mL.
Physical Examination
The following physical findings should prompt the clinician to consider these
conditions:
• Distended neck veins → pericardial tamponade, tension pneumothorax, cardiogenic
failure, air embolism
• "Seat belt sign" → deceleration or vascular injury; chest wall contusion/abrasion
• Paradoxical chest wall movement → flail chest
• Facial/neck swelling or cyanosis → superior mediastinum injury with occlusion or
compression of superior vena cava (SVC)
• Subcutaneous emphysema → torn bronchus or lung parenchyma laceration
• Scaphoid abdomen → diaphragmatic injury with herniation of abdominal content
into the chest
• Excessive abdominal movement with breathing → chest wall injury
Treatment
• Minimal collection of blood (defined as less than 300 ml) in the
pleural cavity generally requires no treatment. Blood usually
reabsorbs throughout the course of several weeks.
• If the patient is stable and has minimal respiratory distress, operative
intervention is not typically required.
• This group of patients can be treated by analgesia as needed and
observed with repeated imaging at 4 to 6 hours and 24 hours
Treatment
• Immediate life-threatening injuries require prompt intervention, such
as decompression needle thoracostomy, and/or emergent tube
thoracostomy for large pneumothoraces
• With an aseptic approach, the tube thoracostomy is placed
posteriorly towards gravity-dependent fluid, in the fourth or fifth
intercostal space between the anterior and mid-axillary line.
• The thoracostomy tube is then connected to a water seal and suction
to facilitate rapid drainage and prevent air leakage. Furthermore, tube
insertion provides for blood quantification to determine if surgical
intervention is needed.
Treatment
According to the literature, indications for surgical intervention (urgent
anterior thoracotomy) include:
• 1500 ml of blood drainage in 24 hours through the chest tube
• 300-500 ml/hour for 2 to 4 consecutive hours after chest tube insertion
• Great vessel or chest wall injury
• Pericardial tamponade
Referensi
• Staub LJ, Biscaro RRM, Kaszubowski E, Maurici R. Chest ultrasonography for
the emergency diagnosis of traumatic pneumothorax and haemothorax: A
systematic review and meta-analysis. Injury. 2018 Mar;49(3):457-466.
• Soni NJ, Franco R, Velez MI, Schnobrich D, Dancel R, Restrepo MI, Mayo PH.
Ultrasound in the diagnosis and management of pleural effusions. J Hosp
Med. 2015 Dec;10(12):811-6.
• Morley EJ, Johnson S, Leibner E, Shahid J. Emergency department
evaluation and management of blunt chest and lung trauma (Trauma
CME). Emerg Med Pract. 2016 Jun;18(6):1-20.
• https://www.sciencedirect.com/topics/nursing-and-health-
professions/hematothorax
• https://www.ncbi.nlm.nih.gov/books/NBK538219/
TERIMA KASIH
Treatment
• Perform initial resuscitation and management of a trauma patient
according to the ATLS protocol.
• Every patient should have two large bore IVs access, be placed on a
cardiac and oxygen monitor, and have a 12-lead EKG.
• Immediate life-threatening injuries require prompt intervention, such
as decompression needle thoracostomy, and/or emergent tube
thoracostomy for large pneumothoraces, and initial management of
hemothorax.