History

Fact Explanation
History of Trauma or Surgical intervention Haemothorax refers to the accumulation of blood in the pleural space following blunt or penetrative trauma to the chest wall, lung parenchyma, heart or great vessels. Less commonly haemothorax can result as any of the following, Complication of an underlying lung pathology [1], bledding diathesis [3], iatrogenic injury [4] or may develop spontaneously.[2]
Chest Pain Results following disruption in the integrity of chest wall and its contents.
Dyspnea Accumulation of blood in the pleural space compromises the proper expansive capacity of the lung. Dyspnea can be sudden or gradual in onset.
References
  1. DI CRESCENZO V, LAPERUTA P, NAPOLITANO F, CARLOMAGNO C, GARZI A, VITALE M. Pulmonary sequestration presented as massive left hemothorax and associated with primary lung sarcoma BMC Surg [online] , 13(Suppl 2):S34 [viewed 14 August 2014] Available from: doi:10.1186/1471-2482-13-S2-S34
  2. KIM JS, HONG JS, PARK YS, AHN JY, SEO YH. Spontaneous haemothorax and haemoperitoneum in Plasmodium vivax malaria. Ann Trop Med Parasitol [online] 2011 Mar, 105(2):177-9 [viewed 16 August 2014] Available from: doi:10.1179/136485911X12899838413664
  3. DOğAN NÖ, PAMUKçU GüNAYDıN G, TEKIN M, CEVIK Y. Nontraumatic massive spontaneous hemothorax with concomitant warfarin use. Case Rep Emerg Med [online] 2013:546024 [viewed 15 August 2014] Available from: doi:10.1155/2013/546024
  4. NETZ U, PERRY Z, LIBSON S, BAYME M. An iatrogenic massive hemothorax. Isr Med Assoc J [online] 2012 Feb, 14(2):135-6 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22693800

Examination

Fact Explanation
Tachypnea Shallow rapid breathing due to respiratory distress.
Reduced chest expansion Complicated chest wall injury disrupting respiratory movements,[1]
Reduced breath sounds in the affected hemithorax Accumulation of blood in the pleural space compromising the expansion of the affected lung.[2]
Dullness to percussion Presence of blood under the surface of percussion alters the note from resonant to dull. [2]
Deviation of trachea to the opposite side Accumulation of large amounts of blood in the pleural space will result in the shifting of the mediastinum to the opposite side.[2]
Hypotesion As a result of profuse systemic blood loss.
Tachycardia Due to profuse systemic blood loss, an attempt to keep the circulatory system intact.
Paradoxical chest wall movements Multiple rib fractures causing a 'flail chest'.[1]
Palpable Crepitus Indicates the prescence of rib fractures.
References
  1. D ABREU AL. THORACIC INJURIES. CRITICAL REVIEW. J Bone Joint Surg Br [online] 1964 Nov:581-97 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14251442
  2. PARRY GW, MORGAN WE, SALAMA FD. Management of haemothorax. Ann R Coll Surg Engl [online] 1996 Jul, 78(4):325-326 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502558

Differential Diagnoses

Fact Explanation
Tension Pneumothorax Will cause a similar clinical picture with rapid deterioration of the patient. Therefore important differential to exclude. Hyperresonant hemithorax on percussion will be a crucial physical finding to differntiate between the two entities.
Pulmonary Contusion May result following blunt chest trauma and most likely will be associated with fracture of the ribs or sternum. Immediate hemoptysis will be present as a result of alveolar capillary disruption.[1] Cyanosis may result due to ventilation perfusion mismatch by fluid accumulation in the alveoli.[2]
Pneumomediastinum Commonly occurs following cervical and thoracic blunt trauma which causes tears in esophagus or rupture of the tracheobronchial tree. Possibilty of pneumomediastinum should be considerd in the presence of the following signs, Subcutaneous emphysema detected in neck, precordial reigons and crunching or rasping sounds heard over the precordium on ascultation. [3]
Chylothorax Occurs due to accumulation of chyle in the pleural cavity following trauma to the thoracic duct. Onset of the symptoms suggestive of respiratory distress will be gradual.[4]
Pleural Empyema Refers to an infected exudative pleural effusion containing pus. Usually presents following infection of parapneumonic effusion. [5] The patient may have a preceding clinical history of pneumonia.
References
  1. IVELY MW. Pulmonary contusion in a collegiate diver: a case report. J Med Case Rep [online] 2011 Aug 10:362 [viewed 15 August 2014] Available from: doi:10.1186/1752-1947-5-362
  2. Result BATCHINSKY AI, WEISS WB, JORDAN BS, DICK EJ JR, CANCELADA DA, CANCIO LC. Ventilation-perfusion relationships following experimental pulmonary contusion. J Appl Physiol (1985) [online] 2007 Sep, 103(3):895-902 [viewed 15 August 2014] Available from: doi:10.1152/japplphysiol.00563.2006
  3. MANSELLA G, BINGISSER R, NICKEL CH. Pneumomediastinum in blunt chest trauma: a case report and review of the literature. Case Rep Emerg Med [online] 2014:685381 [viewed 15 August 2014] Available from: doi:10.1155/2014/685381
  4. AKPINAR V, DURAN FY, DUMAN E, OZKALKANLI MY, DURAN O, HORSANALI B. Bilateral chylhotorax after falling from height. Case Rep Surg [online] 2014:618708 [viewed 15 August 2014] Available from: doi:10.1155/2014/618708
  5. AHMED O, ZANGAN S. Emergent management of empyema. Semin Intervent Radiol [online] 2012 Sep, 29(3):226-30 [viewed 15 August 2014] Available from: doi:10.1055/s-0032-1326933

Investigations - for Diagnosis

Fact Explanation
Upright Chest X-Ray Is the primary mode of imaging to assess the presence of fluid within the pleural cavity. Although it requires minimum amount of 400-500mls of blood to obliterate the costo-phrenic angle.[1]
Ultrasound Is a sensitive,specific and accurate method to detect presence of hemothorax.[2] It can be used to detect small hemothoraces although it may be difficult to detect any coexisting rib fractures or pneumothorax with relation the upright chest xray.[1]
Computed Tomography If diagnosis is in doubt can be used as a complementary investigation. However CT is considered more sensitive than the plain chest xray in diagnosing haemothoraces.[1]
References
  1. MOWERY NT, GUNTER OL, COLLIER BR, DIAZ JJ JR, HAUT E, HILDRETH A, HOLEVAR M, MAYBERRY J, STREIB E. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma [online] 2011 Feb, 70(2):510-8 [viewed 15 August 2014] Available from: doi:10.1097/TA.0b013e31820b5c31
  2. MCEWAN K, THOMPSON P. Ultrasound to detect haemothorax after chest injury. Emerg Med J [online] 2007 Aug, 24(8):581-2 [viewed 15 August 2014] Available from: doi:10.1136/emj.2007.051334

Investigations - Followup

Fact Explanation
Computed Tomography Is considered of great value in a patient with hemothorax for localization & quantification of any retained collections of clots within the pleural space.[1]
References
  1. MOWERY NT, GUNTER OL, COLLIER BR, DIAZ JJ JR, HAUT E, HILDRETH A, HOLEVAR M, MAYBERRY J, STREIB E. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma [online] 2011 Feb, 70(2):510-8 [viewed 15 August 2014] Available from: doi:10.1097/TA.0b013e31820b5c31

Management - General Measures

Fact Explanation
Advanced Trauma Life Support To stabilize the patient by identifying the immediate threats to life such as, changes in respiratory effort, cyanosis, hemodynamic instability. And to correct them as required by adhering to the ATLS protocols to improve the clinical outcome until specific management is done.[1]
Oxygen via face mask. To correct any hypoxia if present.
Appropriate fluid resuscitation. To avoid circulatory collapse in a hemodynamically unstable patient.
Analgesics Pain relief
References
  1. STIELL IG, NESBITT LP, PICKETT W, MUNKLEY D, SPAITE DW, BANEK J, FIELD B, LUINSTRA-TOOHEY L, MALONEY J, DREYER J, LYVER M, CAMPEAU T, WELLS GA, OPALS STUDY GROUP. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ [online] 2008 Apr 22, 178(9):1141-52 [viewed 16 August 2014] Available from: doi:10.1503/cmaj.071154

Management - Specific Treatments

Fact Explanation
Tube Thoracostomy To facilitate the evacuation of hemothorax through the drainage tube and restore the complete expansive capacity of the affected lung. Note - Following the placement of the drainage tube a Chest X-Ray must be performed to identify the correct placement of the tube and complete drainage of the hemothorax.[1]
Thoracotomy Is indicated urgently in the presence of a massive hemothorax which is defined by the following criteria.[2] More than 1500 mL of blood immediately evacuated by correctly placed tube thoracostomy, persistent bleeding from the chest tube (defined as 150 mL/h to 200 mL/h for 2 hours to 4 hours) or persistently required blood transfusions to maintain hemodynamic stability.
Primary Video-Assisted Thoracoscopy Hemodynamically stable patients can be subjected to this method inorder to identify bleeding sources accurately and to evacuate any retained hemothoraces. VATS performed early has shown to reduce the amount of postoperative complications and length of hospital stay when compared with conventional therapy.[3],[4]
Intrapleural Fibrinolysis Complication of hemothorax is retained blood due to improper acute management. If left unattended this can result in pleural infection and empyema. If VATS is not available intrapleural fibrinolysis is considered as an effective alternative.[5]
References
  1. BOERSMA WG, STIGT JA, SMIT HJ. Treatment of haemothorax. Respir Med [online] 2010 Nov, 104(11):1583-7 [viewed 16 August 2014] Available from: doi:10.1016/j.rmed.2010.08.006
  2. MOWERY NT, GUNTER OL, COLLIER BR, DIAZ JJ JR, HAUT E, HILDRETH A, HOLEVAR M, MAYBERRY J, STREIB E. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma [online] 2011 Feb, 70(2):510-8 [viewed 15 August 2014] Available from: doi:10.1097/TA.0b013e31820b5c31
  3. LIN HL, HUANG WY, YANG C, CHOU SM, CHIANG HI, KUO LC, LIN TY, CHOU YP. How early should VATS be performed for retained haemothorax in blunt chest trauma? Injury [online] 2014 Sep, 45(9):1359-64 [viewed 15 August 2014] Available from: doi:10.1016/j.injury.2014.05.036
  4. DE REZENDE-NETO JB, PASTORE NETO M, HIRANO ES, RIZOLI S, NASCIMENTO B JR, FRAGA GP. [Management of retained hemothoraces after chest tube thoracostomy for trauma]. Rev Col Bras Cir [online] 2012 Jul-Aug, 39(4):344-9 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22936236
  5. AGARWAL R, AGGARWAL AN, GUPTA D. Intrapleural fibrinolysis in clotted haemothorax. Singapore Med J [online] 2006 Nov, 47(11):984-6 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17075670