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Hemothorax Riyad Karmy-Jones*, Cassandra Sappington and Nichole Wheeler 268 Current Respiratory Medicine Reviews, 2012, 8, 268-273 Hemothorax Riyad Karmy-Jones*, Cassandra Sappington and Nichole Wheeler Peace Health SouthWest Washington Medical Center, Vancouver, WA 98664, USA Abstract: Hemothorax is most commonly seen following trauma or iatrogenic injury, but can be related to underlying medical issues. The primary issue to be determine dis whether or not the patient is stable and/or has ongoing hemorrhage. Simple tube thoracostomy usually suffices to manage the problem, but specific subsets of patients are at increased risk of complications, notably empyema. The role, type and timing of surgical intervention depends upon patient stability, underlying etiology and co-existing medical variables. Keywords: Empyema, hemothorax, thoracotomy, VATS. INTRODUCTION regardless of the etiology, will be best served by operative intervention. Hemothorax has been defined as a pleural fluid collection with a hematocrit at least 50% of the peripheral blood [1]. The acute complications can involve cardiac decompensation INITIAL MANAGEMENT AND DIAGNOSIS as a consequence of hypovolemia and/or cardiac tamponade. In most cases, hemothorax is self-evident and plain chest Respiratory failure can result from the former as well as lung radiography is sufficient. However, particularly in non- collapse. The primary sub-acute and chronic complication is trauma cases, it may not be immediately apparent clinically. the risk of empyema. The majority of experience with Suspicion may be roused by signs of hypovolemia, chest hemothorax comes from the trauma population, although pain and/or shortness of breath. It may present in a delayed there are a number of non-traumatic etiologies as well (Table 1). fashion (e.g. after treatment for pulmonary embolism) and Table 1. A Short List of Etiology of Hemothorax determining to what extent a “small” or “moderate” hemothorax is contributing to the clinical picture may be difficult. In medical patients, pleural aspiration is often Traumatic performed initially to confirm the diagnosis [1]. CT scan can Iatrogenic show a pleural effusion with “typical” density of 50-100 Hounsfield units. In addition, a source of bleeding may be - Central line insertion seen (“blush” or “active extravasation”) if intra-venous - Pulmonary catheter contrast is administered. - Lung biopsy - Chest wall biopsy The initial management in all but those patients with small hemothoraces who are completely stable is tube - Sclerotherapy of varices drainage. While percutaneous catheters can be used, in - Post-operative general they are too small to be effective and drains of 28 Fr. - Complication of anticoagulation (particularly for PE) or greater are required to have a reasonable chance to - Aspiration of pleural fluid evacuate the blood. Based on the trauma literature, antibiotic “Spontaneous” prophylaxis should be given. Ideally these should cover - Pneumothorax gram-positive organisms, and first generation cephalosporins - Chest wall tumors should be used. It appears that in the trauma population 24- - Pleural metastases hours of coverage is appropriate, with no clear data regarding more prolonged coverage except in specific - Endometriosis situations [2]. These guidelines seem to fit the non-trauma - Rupture of internal mammary or intercostal arteries population as well [1]. - Thoracic aneurysm/dissection - Rupture of pulmonary artery malformations The next decision is to determine whether or not the patient requires an immediate operation. This will be determined by the patient’s stability. In the presence of The primary question in the setting of hemothorax is not hemodynamic compromise, usually immediate surgery is the underlying etiology, but whether or not the patient is required. Simultaneous transfusion, correction of coagulation stable. In unstable patients, the vast majority of patients, parameters (if possible) and respiratory support may be necessary. Large bore access should be employed for aggressive volume resuscitation. In the civilian sector there *Address correspondence to this author at the Peace Health SouthWest has been growing consensus that blood product rather than Washington Medical Center, 505 87th Ave Suite 301 Bldg B, Vancouver, crystalloid resuscitation, combined with short-term WA 98664, USA; Tel: 360-514-1854; E-mail: [email protected] “hypotensive” resuscitation (goal of systolic blood pressure 90 mmHg) may be associated with improved outcomes. This 1875-6387/12 $58.00+.00 © 2012 Bentham Science Publishers Hemothorax Current Respiratory Medicine Reviews, 2012, Vol. 8, No. 4 269 concept is based on the premise that large volumes of contamination) and as blood is a potent bacterial growth crystalloid will simply drive up blood pressure transiently, medium as well as being rich in fibrin there is early and thereby re-starting bleeding, as well as further dilute critical vigorous colonization and loculation formation [17]. components required for the clotting cascade [3, 4]. The Thus, even in the absence of signs of infection, retained most recent and ongoing military experience supports this hemothorax can be an indication for intervention. concept [5]. That being said, in the civilian setting, this Documenting the true volume of hemothorax as well as requires that definitive control be obtained within 1-2 hours extent of loculations can be difficult. Plain radiography often at most, and as a practical matter the very unstable patient is underestimates the volume and nature of the fluid collection going to the operating theater within minutes. With that in [18]. Ultra-sound and CT scan have been shown to be able to mind, it is better to follow one’s own instinct and prepare for identify occult or larger than expected collections of pleural any type and volume of fluid that is required and that the fluid (Figs. 1 & 2) [10, 18, 19]. However, because CT scan treating surgeon feels is appropriate. in particular is so sensitive, it is not clear what volume of Patients who are not unstable, or who respond to retained hemothorax (in absence of other indications for resuscitation and maintain stability, usually afford some time intervention) would be a clear cut indication for further to determine the underlying etiology which may offer interventions. An American Association for the Surgery of alternatives to thoracotomy. However, unless the patient is Trauma multi-center trial is currently addressing this issue completely stable, constant vigilance is required. but at the current time the decision remains individualized. INTERVENTION BASED ON VOLUME OF OUTPUT In the absence of hemodynamic instability, or a specific diagnosis that requires intervention, the volume of ongoing chest tube output has been used to determine if an intervention (usually operative) is required. Relatively recently, an initial output of 1500 ml or ongoing output of 250 ml/hr for 3 consecutive hours has been the standard [6]. In practice, the concept of observing chest tube output can be problematical. Tubes can vary in volume or become plugged, and it is not always certain that close monitoring is possible. The authors who originated the “1500 ml limit” actually noted that the absolute value over a short period (usually less than 24 hours) was an acceptable and relevant marker for the need of intervention [7, 8]. The use of the “1500 ml in 24- hour limit” in trauma patients was re-validated by a multi- center study that demonstrated a 3.2-fold increase in mortality if thoracotomy was performed after a total of 1500 cc blood loss in a 24-hour period [9]. How this applies to the non-trauma/non-iatrogenic setting is not clear. Given that patients with a high volume of output are at risk for worsening coagulopathy, perturbations in fluid and electrolyte balance and multiple organ stress, it would seem that this is an appropriate indicator for more aggressive intervention in this population as well [10]. The exception to the 1500 ml rule would the patient who presents in a delayed fashion. It is not uncommon for patients to have 2-3 liters of blood and/or reactive fluid days after an inciting event. In the absence of hemodynamic Fig. (1). Patient who presented with pneumothorax and rib fracture changes, simple tube drainage is sufficient. with clear chest radiograph after tube placement. The next day he was slightly febrile and tachycardic. RETAINED HEMOTHORAX Not all hemothoraces need to be drained. Hemodynami- Chest tubes fail to completely evacuate hemothorax in at cally stable patients with small effusions or those that appear least 5-10% of cases [11-13]. The primary complication of a in a delayed fashion may be observed. Our criteria includes partially drained hemothorax is empyema, which can occur the following: No sign of infection; patient able to in as many as 30% of patients, particularly after trauma [12, participate in pulmonary toilet; the effusion has not had a 14]. Trapped lung or fibrothorax has also been discussed as a tube placed. Many of these will increase in volume initially long term complication, but the current consensus is that this (secondary to inflammatory changes) but in the majority of really reflects occult empyema or other pleural inflammatory cases will resolve spontaneously without the need for processes that exacerbate pleural scarring [15, 16]. Empyema intervention (Figs. 3 & 4). Bilello et al. suggested that hemo- following hemothorax differs from the more common para- thoraces following trauma that are < 1.5 cm in depth can be pneumonic empyema in that there tends to
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