Hemothorax is bleeding into the pleural cavity, accumulation of blood between its leaves, leading to compression of the lung and displacement of the mediastinal organs in the opposite direction. With hemothorax, there is chest pain, difficulty breathing, signs of acute blood loss develop (dizziness, pallor of the skin, tachycardia, hypotension, cold sticky sweat, fainting). Diagnosis is based on physical data, results of chest X-ray, CT, diagnostic pleural puncture. Treatment includes hemostatic, antibacterial, symptomatic therapy; aspiration of accumulated blood (punctures, drainage of the pleural cavity), if necessary – open or videothoracoscopic removal of the coagulated hemothorax, stopping ongoing bleeding.
ICD 10
J94.2 Hemothorax
Meaning
Hemothorax is the second most common (after pneumothorax) complication of chest injuries and occurs in 25% of patients with thoracic trauma. Quite often in clinical practice there is a combined pathology – hemopneumothorax. The danger of disease is both in increasing respiratory failure due to compression of the lung, and in the development of hemorrhagic shock due to acute internal bleeding. In pulmonology and thoracic surgery, disease is regarded as an emergency condition requiring emergency specialized care.
Hemothorax causes
There are three groups of causes that most often lead to the development of disease: traumatic, pathological and iatrogenic.
Traumatic causes are understood as penetrating wounds or closed chest injuries. Thoracic trauma, accompanied by the development of disease, includes road accidents, gunshot and knife wounds of the chest, rib fractures, falls from a height, etc. With such injuries, quite often there is damage to the organs of the thoracic cavity (heart, lungs, diaphragm), abdominal organs (liver, spleen injuries), intercostal vessels, internal thoracic artery, intra-thoracic branches of the aorta, blood from which pours into the pleural cavity.
The causes of hemothorax of a pathological nature include various diseases: lung or pleural cancer, aortic aneurysm, pulmonary tuberculosis, lung abscess, neoplasms of the mediastinum and chest wall, hemorrhagic diathesis, coagulopathy, etc.
Iatrogenic factors leading to the development of hemothorax are complications of operations on the lungs and pleura, thoracocentesis, drainage of the pleural cavity, catheterization of central veins.
Pathogenesis
The accumulation of blood in the pleural cavity causes compression of the lung on the side of the lesion and displacement of the mediastinal organs in the opposite direction. This is accompanied by a decrease in the respiratory surface of the lung, the occurrence of respiratory disorders and hemodynamics. Therefore, with hemotrax, a clinic of hemorrhagic and cardio-pulmonal shock with acute respiratory and heart failure often develops.
Already in the next few hours after blood enters the pleural cavity, aseptic inflammation of the pleura develops – hemopleuritis, due to the reaction of pleural leaflets. With hemothorax, there is edema and moderate leukocyte infiltration of the pleura, swelling and peeling of mesothelial cells. In the initial period, the blood poured into the pleural cavity practically does not differ in composition from peripheral blood. In the future, there is a decrease in hemoglobin, a decrease in the erythrocyte-leukocyte index.
Getting into the pleural cavity, the blood first coagulates. However, then the process of fibrinolysis soon begins, and the blood is re-thinned. This is facilitated by anticoagulant factors contained in the blood itself and pleural fluid, as well as mechanical defibrination of blood due to respiratory excursion of the chest. As the anticoagulation mechanisms are depleted, blood clotting and the formation of a coagulated hemothorax occurs. In the case of attachment of microbial infection against the background of hemothorax, empyema of the pleura can occur quite quickly.
Classification
In accordance with the etiology, traumatic, pathological and iatrogenic form are distinguished. Taking into account the magnitude of intrapleural bleeding, the hemothorax may be:
- small – volume of blood loss up to 500 ml, accumulation of blood in the sinus;
- average – volume up to 1.5 liters, blood level up to the lower edge of the IV rib;
- subtotal – volume of blood loss up to 2 liters, blood level up to the lower edge of the II rib;
- total – the volume of blood loss over 2 liters, radiologically characterized by total darkening of the pleural cavity on the side of the lesion.
The amount of blood poured into the pleural cavity depends on the location of the wound and the degree of vascular destruction. Thus, when the peripheral parts of the lung are damaged, in most cases a small or medium hemothorax occurs; when the root of the lung is injured, the main vessels are usually damaged, which is accompanied by massive bleeding and the development of subtotal and total hemothorax.
In addition, a limited (usually small in volume) hemothorax is also isolated, in which the spilled blood accumulates between pleural adhesions, in an isolated area of the pleural cavity. Taking into account the localization, a limited hemothorax can be apical, interlobular, paracostal, supradiaphragmatic, paramediastinal.
In the case of continued intrapleural bleeding, they speak of an increasing hemothorax, in the case of cessation of bleeding – of non-growing (stable). Complicated types include clotted and infected hemothorax (pyohemothorax). When air and blood enter the pleural cavity at the same time, they talk about hemopneumothorax.
Hemothorax symptoms
The clinical symptoms of hemothorax depend on the degree of bleeding, compression of lung tissue and displacement of mediastinal organs. With a small hemothorax, clinical manifestations are minimal or absent. The main complaints are chest pains, aggravated by coughing, moderate shortness of breath.
With a hemothorax of medium or large size, respiratory and cardiovascular disorders develop, expressed to varying degrees. There is a sharp pain in the chest, radiating into the shoulder and back when breathing and coughing; general weakness, tachypnea, decreased blood pressure. Even with minor physical exertion, symptoms increase. The patient usually assumes a forced sitting or semi-sitting position.
With severe hemothorax, the clinic of intrapleural bleeding comes to the fore: weakness and dizziness, cold sticky sweat, tachycardia and hypotension, pallor of the skin with a cyanotic tinge, flashing flies before the eyes, fainting.
Hemothorax associated with rib fracture is usually accompanied by subcutaneous emphysema, soft tissue hematomas, deformity, pathological mobility and crepitation of rib fragments. With a hemothorax occurring with a rupture of the pulmonary parenchyma, hemoptysis may occur.
In 3-12% of cases, a coagulated hemothorax is formed, in which blood clots, fibrin layers and moorings form in the pleural cavity, limiting the respiratory function of the lung, causing the development of sclerotic processes in the lung tissue. The clinic of coagulated hemothorax is characterized by heaviness and pain in the chest, shortness of breath. With an infected hemothorax (empyema of the pleura), signs of severe inflammation and intoxication come to the fore: fever, chills, lethargy, etc.
Diagnostics
To make a diagnosis, the details of the history of the disease are clarified, physical, instrumental and laboratory examination is carried out. With hemothorax, the lag of the affected side of the chest during breathing is determined, the dulling of the percussion sound above the liquid level, the weakening of breathing and vocal trembling. With X-ray and overview lung x-ray, lung collapse, the presence of a horizontal level of fluid or clots in the pleural cavity, flotation (displacement) of the mediastinal shadow to the healthy side is revealed.
For diagnostic purposes, a puncture of the pleural cavity is performed: receiving blood reliably indicates a hemothorax. To differentiate the sterile and infected hemothorax, Petrov and Efendiev samples are carried out with an assessment of the transparency and precipitation of the aspirate. In order to judge the cessation or continuation of intrapleural bleeding, a Rouvilois-Gregoire test is performed: the coagulation of the received blood in a test tube or syringe indicates continued bleeding, the absence of coagulation indicates the cessation of bleeding. Punctate samples are sent to the laboratory to determine hemoglobin and conduct a bacteriological study.
With a banal and coagulated hemothorax, they resort to laboratory determination of Hb, the number of erythrocytes, platelets, and coagulogram examination. Additional instrumental diagnostics for hemothorax may include ultrasound of the pleural cavity, rib radiography, chest CT, diagnostic thoracoscopy.
Hemothorax treatment
Patients with hemothorax are hospitalized in specialized surgical departments and are under the supervision of a thoracic surgeon. For therapeutic purposes, for aspiration / evacuation of blood, the pleural cavity is drained with the introduction of antibiotics and antiseptics into the drainage (to prevent infection and sanitation), proteolytic enzymes (to dissolve clots). Conservative treatment of hemothorax includes hemostatic, disaggregant, symptomatic, immunocorrective, hemotransfusion therapy, general antibiotic therapy, oxygen therapy.
Small hemothorax in most cases can be eliminated conservatively. Surgical treatment of hemothorax is indicated in the case of ongoing intrapleural bleeding; with a coagulated hemothorax that prevents the expansion of the lung; damage to vital organs.
In case of injury to large vessels or organs of the thoracic cavity, an emergency thoracotomy is performed, the vessel is ligated, the wound of the lung or pericardium is sutured, the blood that has poured into the pleural cavity is removed. A coagulated hemothorax is an indication for routine videothoracoscopy or open thoracotomy to remove blood clots and sanitize the pleural cavity. With suppuration of the hemothorax, treatment is carried out according to the rules of purulent pleurisy.
Prognosis and prevention
The success of hemothorax treatment is determined by the nature of the injury or disease, the intensity of blood loss and the timeliness of surgical care. The prognosis is most favorable for small and medium uninfected hemothorax. A clotted hemothorax increases the likelihood of developing pleural empyema. Continued intrapleural bleeding or simultaneous large blood loss can lead to the death of the patient.
The outcome of a hemothorax may be the formation of massive pleural accretions that limit the mobility of the diaphragm dome. Therefore, during the rehabilitation period, swimming and breathing exercises are recommended for patients who have undergone hemothorax. Prevention of hemothorax consists in the prevention of injuries, mandatory consultation of patients with thoracoabdominal trauma by a surgeon, control of hemostasis during operations on the lungs and mediastinum, careful performance of invasive manipulations.
Literature
- Brooks A, Davies B, Smethhurst M, Connolly J. Emergency ultrasound in the acute assessment of haemothorax. Emerg Med J. 2004 Jan;21(1):44-6. – link
- Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Cochrane Database Syst Rev. 2018 Dec 12;12(12):CD012669. link
- Abboud PA, Kendall J. Emergency department ultrasound for hemothorax after blunt traumatic injury. J Emerg Med. 2003 Aug;25(2):181-4. – link
- McEwan K, Thompson P. Ultrasound to detect haemothorax after chest injury. Emerg Med J. 2007 Aug;24(8):581-2. link
- 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. – link
