Haemothorax - Clinicals, Diagnosis, and Management

Trauma

Clinicals - 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 , bledding diathesis , iatrogenic injury or may develop spontaneously. 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 , bledding diathesis , iatrogenic injury or may develop spontaneously.
Chest Pain Results following disruption in the integrity of chest wall and its contents. 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. Dyspnea
Accumulation of blood in the pleural space compromises the proper expansive capacity of the lung. Dyspnea can be sudden or gradual in onset.

Clinicals - Examination

Fact Explanation
Tachypnea Shallow rapid breathing due to respiratory distress. Tachypnea
Shallow rapid breathing due to respiratory distress.
Reduced chest expansion Complicated chest wall injury disrupting respiratory movements, Reduced chest expansion
Complicated chest wall injury disrupting respiratory movements,
Reduced breath sounds in the affected hemithorax Accumulation of blood in the pleural space compromising the expansion of the affected lung. Reduced breath sounds in the affected hemithorax
Accumulation of blood in the pleural space compromising the expansion of the affected lung.
Dullness to percussion Presence of blood under the surface of percussion alters the note from resonant to dull. Dullness to percussion
Presence of blood under the surface of percussion alters the note from resonant to dull.
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. 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.
Hypotesion As a result of profuse systemic blood loss. Hypotesion
As a result of profuse systemic blood loss.
Tachycardia Due to profuse systemic blood loss, an attempt to keep the circulatory system intact. 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'. Paradoxical chest wall movements
Multiple rib fractures causing a 'flail chest'.
Palpable Crepitus Indicates the prescence of rib fractures. Palpable Crepitus
Indicates the prescence of rib fractures.

Investigations - 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. 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.
Ultrasound Is a sensitive,specific and accurate method to detect presence of hemothorax. 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. Ultrasound
Is a sensitive,specific and accurate method to detect presence of hemothorax. 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.
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. 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.

Investigations - Management

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. 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.

Management - Supportive

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. 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.
Oxygen via face mask. To correct any hypoxia if present. Oxygen via face mask.
To correct any hypoxia if present.
Appropriate fluid resuscitation. To avoid circulatory collapse in a hemodynamically unstable patient. Appropriate fluid resuscitation.
To avoid circulatory collapse in a hemodynamically unstable patient.
Analgesics Pain relief Analgesics
Pain relief

Management - Specific

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.
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.
Thoracotomy Is indicated urgently in the presence of a massive hemothorax which is defined by the following criteria.
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.
Thoracotomy
Is indicated urgently in the presence of a massive hemothorax which is defined by the following criteria.
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., 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.,
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. 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.

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