sign in sign up
<<
Home , Pulmonary hypertension

268 Current Respiratory Medicine Reviews, 2012, 8, 268-273 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 can result from the former as well as 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 . 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 ) 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 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 - 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 population as well [1]. - Thoracic / - Rupture of pulmonary 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 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 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 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 be a safely observed [20]. predominance of gram-positive organisms (possibly due to 270 Current Respiratory Medicine Reviews, 2012, Vol. 8, No. 4 Karmy-Jones et al.

reviewed their experience with 118 patients over a 5-year period who underwent intra-pleural alteplase (25 mg)

injection, 13 (11%) of which were due to hemothorax (non- traumatic). Overall, between 1-8 doses were utilized. Eight (61.5%) of the hemothorax patients were successfully managed (the remainder required operative intervention) with no exacerbation of hemorrhage [22]. Oguzkaya et al. retrospectively compared the course of 31 patients who underwent intra pleural streptokinase instillation to 34 who underwent thoracoscopic drainage of post traumatic hemothorax. Nine (29%) of the streptokinase group required thoracotomy and three (10%) developed empyema. In contrast only two (6%) of the primary thoracoscopy group required thoracotomy and no empyema was documented. The length of stay was significantly shorter in the thoracoscopy group [23]. It should be noted, however, that a leading indication of “failure of therapy” was radiographic rather than clinical findings. Our own bias is that lytic

therapy would be expected to fail especially if dense Fig. (2). CT shows markedly greater fluid collection. At loculations have formed, and we prefer to limit its use to thoracoscopy 2000 cc of blood was drained. post-surgical clearance if early “soft” loculations or retained clots are suspected. The trauma literature supports this approach with the additional comment that retained hemothorax in patients at prohibitive risk for operative intervention may be appropriate candidates for lytic therapy [10]. Lytic installation can be effective if the primary issue is clotted blood obstructing the chest tube. In patients not at obvious risk for bleeding (fresh post-operative suture lines, documentation of an active bleeding site not directly addressed) there does not appear to be a risk of “creating” bleeding with intra pleural lytic therapy [1].

Fig. (3). Patient who presented with pleural effusion three days post blunt trauma with grade I spleen injury managed non-operatively. The past medical history was notable for . The patient was managed with incentive . Interventions for retained hemothorax can include further tube drainage, instillation of lytics and/or surgery. Meyer and colleagues compared patients following trauma who were randomized to a second chest tube vs thoracoscopy. Patients undergoing thoracoscopy had a shorter length of stay and hospital cost. In contrasts, 40% of patients randomized to a second chest tube had a failure requiring operation, with Fig. (4). Same patient three months later. increased likelihood of thoracotomy [21]. Intra-pleural Thus, there is a general bias favoring early (< 5-7 days) thrombolytics have been successfully used for draining thoracoscopic drainage of retained hemothorax, with the retained hemothoraces. In one study, Kimbrell and associates understanding that thoracoscopy is both more likely to described management of undrained traumatic hemothorax succeed without the need for thoracotomy, as well as being in 25 patients, using either streptokinase or urokinase. Only more successful and reducing complications and hospital two (8%) patients failed therapy [13]. Ben-Or and colleagues stay [10].

Hemothorax Current Respiratory Medicine Reviews, 2012, Vol. 8, No. 4 271

MANAGEMENT BASED ON ETIOLOGY experience, there usually was an inciting event. It is often so minor that the patient did not link the event (a minor fall, Traumatic injuries that go to surgery are usually operated “pulled muscle” etc) to the onset of hemothorax. Patients on acutely to exclude or treat recognized injuries (cardiac, being treated for present with or chest wall, lung etc) and/or because of a combination of develop effusions in up to 50% of cases. These are usually and/or evidence of ongoing blood loss. It has exudative and involve less than 1/3 of the hemothorax (often been estimated that roughly 300,000 cases of traumatic just minimal blunting of the costophrenic angle) [30, 31]. hemothorax occur annually in the United States [24]. Thus it However, active bleeding can occur, occasionally due to is not surprising that the majority of experience comes from lung infarction and necrosis [32]. If any effusion increases the trauma literature. However, the subject is too broad to while on anticoagulation therapy, pleural aspiration to rule cover in detail. Suffice it to say that in unstable patients, out hemothorax is reasonable, followed by correction of thoracotomy is usually performed, in stable patients anticoagulation and drainage [31]. thoracoscopy may be an option, and in specific subsets other approaches (such as catheter based embolization or stenting) The most common etiology of spontaneous hemothorax may be appropriate. is rupture of pleural bands, presenting as a spontaneous hemothorax. 1 Patients with spontaneous pneumothorax often catheter induced pulmonary rupture is have well vascularized adhesions to the pleural apex, and up becoming rarer as these become less used. The overall to 5% of patients with spontaneous pneumothorax can have incidence may be as low as 0.2% [25, 26]. Risk factors hemothorax as well [33]. These can be simply managed by include: thoracoscopic clipping and bleb resection at the same setting. 1. Age > 60 Young patients who present with spontaneous hemo- 2. Pulmonary thorax, in the absence of pneumothorax, may have inherited vascular and/or coagulation disorders. These include Ehlers- 3. Distal placement (> 5 cm to lateral on Danlos type 4, Osler-Weber-Rendu syndrome, neurofibro- chest radiograph) matosis type I, hemophilia, Glanzman thrombasthenia [34]. 4. Systemic heparinization These conditions may be associated with spontaneous 5. rupture of lung parenchyma, pulmonary artery and/or chest wall vessels (including internal mammary artery). Usually The most common site of rupture is the middle lobe chest drainage is sufficient but more specific intervention artery, followed by the lingular artery [27]. While generally (including catheter occlusion or surgery) may be required associated with hemoptysis, free intra-thoracic bleeding can [35]. occur and requires operative repair. Pulmonary arteriovenous malformation rarely is Complications related to central venous access (including associated with hemothorax but may be suggested by history rare right atrial injury) can be managed by simply removing and physical (prior diagnosis, family history, history of nose the line and draining the chest, but if there is a large fluid bleeds, telangectasias etc) and confirmed by CT scan. Both collection or signs of ongoing bleeding, surgery is usually catheter occlusion and operative resection have been preferred. This can be accomplished thoracoscopically as the described based on patient stability [36, 37]. bleeding is usually “low pressure” and control is achieved by applying focal pressure, biological glues or even It can be particularly difficult to decide on the optimal thoracoscopic sutures. The positive pressure applied during management of patients with inherited disorders of general anesthesia will also tend to tamponade the bleeding coagulation. Clearly, immediate steps must be taken to site. As noted earlier, the patient should be hemodynamically correct or reverse the coagulopathy. In stable patients who stable to perform thoracoscopic approaches. do not have significant cardio-respiratory compromise, it may be possible to correct the abnormalities prior to tube Ironically, bleeding from intercostal artery injury from an thoracostomy (if needed) or to manage them conservatively attempted thoracentesis (“traumatic tap”) is probably more with tube thoracostomy and blood products alone [38]. common than reported. Intercostal injury can also occur Unfortunately, if the patient is unstable, and thoracotomy is from subcutaneous injections (during breast biopsy or breast required, one can anticipate continued diffuse bleeding [39]. augmentation for example) or during chest tube placement. These small arteries can bleed at a surprising rate. As with Hemothorax secondary to metastases, pleural exostoses, other causes of hemothorax, in the acute setting chest tube endometriosis etc if small and the patient is stable can be drainage is the first step. If there is ongoing blood loss, managed by simple tube drainage and treating the underlying usually thoracoscopy is sufficient. Thoracoscopy may also lesion. More significant hemorrhage requires thoracotomy (in the setting of attempted pleural aspiration) serve an and may entail resection of the offending lesion [40, 41]. important diagnostic function as well. Thoracic endometriosis more commonly presents as spontaneous/recurring pneumothorax. Hemothorax was Spontaneous hemothorax as a complication of noted in 12% of documented cases in one series and anticoagulation therapy is rare, and responds to drainage and reflected increased volume of parietal and visceral pleural reversal of the offending agent [28]. Braithwaite and implants [42]. While gonadotropin-releasing hormone colleagues noted that two of 70 (3%) of low risk trauma antagonists have been recommended in the management of patients in the post-injury phase developed hemothorax extra pelvic endometriosis, surgical resection is very following anticoagulation therapy [29]. In our limited effective [43].

272 Current Respiratory Medicine Reviews, 2012, Vol. 8, No. 4 Karmy-Jones et al.

TECHNIQUES OF INTERVENTION CONCLUSION The most basic intervention for managing hemothorax is The primary management of hemothorax is drainage. In tube thoracostomy. In the majority of cases the primary patients who are unstable, early intervention (usually therapeutic goal is to simply drain the hemothorax and allow operative) is required. In stable patents, evidence of ongoing the lung to expand. This will remove local lytic products bleeding requires intervention. Depending on stability and which will aggravate bleeding as well as permit the lung to origin a variety of operative or interventional approaches tamponade any site of bleeding. Although a “simple” may be used. Patients with retained hemothorax after tube procedure, it can be quite traumatic to the patient. Careful drainage are at increased risk for empyema and consideration attention to pain control, liberal use of local anesthesia, and should be given for early thoracoscopic drainage. sterile technique is critical. In general, the goal is to direct the tube posteriorly, which can be quite difficult as the ACKNOWLEDGEMENT curvature of the chest tends to direct the tube more medially and anteriorly than usually anticipated. In patients who have Declared none. had a prior thoracotomy, the tube should be placed above the thoracotomy scar to avoid injuring the diaphragm. Going CONFLICT OF INTEREST above the infra-mammary crease should reduce inadvertent abdominal injury. Our own bias is to not “tunnel” the tube Declared none. except in very thin patients. We also use a sharp technique to enter the chest, using scissors or a scalpel to incise the REFERENCES intercostal muscles, entering finally with our finger. This [1] Boersma WG, Stigt JA, Smit HJ. Treatment of haemothorax. will prevent inadvertent cardiac or pulmonary laceration, and Respir Med 2010; 104: 1583-7. is less painful. [2] Luchette FA, Barrie PS, Oswanski MF, et al. Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for Thoracoscopy usually refers to video-assisted thoracic traumatic : the east practice management surgery (VATS). This requires that the lung on the operative guidelines work group. eastern association for trauma. J Trauma side be deflated. Thus, coordination with anesthesia is 2000; 48: 753-7. critical. Options include dual-lumen intubation or the use of [3] Sambasivan CN, Schreiber MA. Emerging therapies in traumatic hemorrhage control. Curr Opin Crit Care 2009; 15: 560-8. endobronchial blockers. If this is not feasible (for example a [4] Mattox KL, Bickell W, Pepe PE, Burch J, Feliciano D. Prospective patient with severe lung injury) pleuroscopy (“rigid MAST study in 911 patients. J Trauma 1989; 29: 1104-11; thoracoscopy”) can be utilized. Generally a mediastinoscope discussion 1111-2. is sufficient, and the pleural space can be effectively drained [5] D'Alleyrand JC, Dutton RP, Pollak AN. Extrapolation of battlefield resuscitative care to the civilian setting. J Surg Orthop Adv 2010; and explored even when lung isolation is not feasible [44]. 19: 62-9. Thoracoscopy can be performed in the acute setting, if the [6] Mansour MA, Moore EE, Moore FA, Read RR. Exigent postinjury patient is hemodynamically stable. Small lesions (peripheral thoracotomy analysis of blunt versus penetrating trauma. Surg lung, diaphragm, intercostal vessels) can be ligated or Gynecol Obstet 1992; 175: 97-101. clipped via VATS. These minimal approaches allow [7] McNamara JJ, Messersmith JK, Dunn RA, Molot MD, Stremple JF. Thoracic injuries in combat casualties in Vietnam. Ann Thorac evacuation of clot, some adhesionolysis, irrigation, and Surg 1970; 10: 389-401. accurate placement of drainage tubes, although the ability to [8] Kish G, Kozloff L, Joseph WL, Adkins PC. Indications for early perform true visceral decortications is limited. thoracotomy in the management of chest trauma. Ann Thorac Surg 1976; 22: 23-8. Thoracotomy or sternotomy may be required depending [9] Karmy-Jones R, Jurkovich GJ, Nathens AB, et al. Timing of urgent on the clinical setting. When there is diffuse bleeding and thoracotomy for hemorrhage after trauma: a multicenter study. instability, damage control thoracotomy, in which the chest Arch Surg 2001; 136: 513-8. [10] Mowery NT, Gunter OL, Collier BR, et al. Practice management is packed open, may allow time to resuscitate the patient. guidelines for management of hemothorax and occult Variations of thoracotomy include “mini-access” using pneumothorax. J Trauma 2011; 70: 510-8. VATS approaches or muscle sparring approaches. These [11] Helling TS, Gyles NR 3rd, Eisenstein CL, Soracco CA. may be required if dense adhesions or pleural peel is Complications following blunt and penetrating injuries in 216 encountered. victims of chest trauma requiring tube thoracostomy. J Trauma 1989; 29: 1367-70. Trans-catheter approaches have been described for a [12] Eren S, Esme H, Sehitogullari A, Durkan A. The risk factors and variety of etiologies, including intercostal, mammary, management of posttraumatic empyema in trauma patients. Injury 2008; 39: 44-9. subclavian and vertebral artery bleeding sources [45]. In [13] Kimbrell BJ, Yamzon J, Petrone P, Asensio JA, Velmahos GC. general, for the smaller vessels, simple coiling or biologic Intrapleural thrombolysis for the management of undrained glue suffices, but occasionally stenting across the main traumatic hemothorax: a prospective observational study. J Trauma artery may be needed. It is important to document whether 2007; 62: 1175-8; discussion 1178-9. [14] Eddy AC, Luna GK, Copass M. Empyema thoracis in patients there are other feeding vessels that supply the area. Thus undergoing emergent closed tube thoracostomy for thoracic trauma. embolization of internal mammary or intercostal arteries Am J Surg 1989; 157: 494-7. requires embolization on both sides of the lesion. We usually [15] Karmy-Jones R, Jurkovich GJ. Blunt chest injury. Curr Probl Surg only pursue catheter based approaches in hemodynamically 2004; 41: 205-380. stable patients. [16] Doelken P, Sahn SA. Trapped lung. Semin Respir Crit Care Med 2001; 22: 631-6.

Hemothorax Current Respiratory Medicine Reviews, 2012, Vol. 8, No. 4 273

[17] Richardson JD, Carrillo E. Thoracic infection after trauma. Chest [33] Homma T, Sugiyama S, Kotoh K, Doki Y, Tsuda M, Misaki T. Surg Clin N Am 1997; 7: 401-27. Early surgery for treatment of spontaneous hemopneumothorax. [18] Velmahos GC, Demetriades D, Chan L, et al. Predicting the need Scand J Surg 2009; 98: 160-3. for thoracoscopic evacuation of residual traumatic hemothorax: [34] Selim B, Lane CR, Rubinowitz AN, Siner JM. Spontaneous chest radiograph is insufficient. J Trauma 1999; 46: 65-70. hemothorax and recurrent hemoptysis in a 26-year-old man with [19] Sisley AC, Rozycki GS, Ballard RB, Namias N, Salomone JP, skin lesions. Chest 2010; 137: 480-3. Feliciano DV. Rapid detection of traumatic effusion using surgeon- [35] Hieda M, Toyota N, Kakizawa H, et al. Endovascular therapy for performed ultrasonography. J Trauma 1998; 44: 291-7. massive haemothorax caused by ruptured extracranial vertebral [20] Bilello JF, Davis JW, Lemaster DM. Occult traumatic hemothorax: artery aneurysm with Type 1. Br J Radiol 2007; when can sleeping dogs lie? Am J Surg 2005; 190: 841-4. 80: e81-4. [21] Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of [36] Berg AM, Amirbekian S, Mojibian H, Trow TK, Smith SJ, White traumatic retained hemothoraces using thoracoscopy: a prospective, RI Jr. Hemothorax due to rupture of pulmonary arteriovenous randomized trial. Ann Thorac Surg 1997; 64: 1396-400; discussion malformation: an interventional emergency. Chest 2010; 137: 705- 1400-1. 7. [22] Ben-Or S, Feins RH, Veeramachaneni NK, Haithcock BE. [37] Zhao Y, Li GY, Yang Z, Zhang P, Zhang K, Shao G. Bilateral Effectiveness and risks associated with intrapleural alteplase by heterochronic spontaneous hemothorax caused by pulmonary means of tube thoracostomy. Ann Thorac Surg 2011; 91: 860-3; arteriovenous malformation in a gravid: a case report. J discussion 863-4. Cardiothorac Surg 2010; 5: 96. [23] Oguzkaya F, Akcali Y, Bilgin M. Videothoracoscopy versus [38] Gidaris D, Economou M, Valeri R, Gombakis N, Athanasiou- intrapleural streptokinase for management of post traumatic Metaxa M. Successful treatment of a spontaneous haemothorax retained haemothorax: a retrospective study of 65 cases. Injury with recombinant factor VIIa in a haemophilic child with 2005; 36:526-9. inhibitors. Hippokratia 2010; 14: 289-90. [24] Richardson JD, Miller FB, Carrillo EH, Spain DA. Complex [39] Lim S, Zuha R, Burt T, Chacko J, Scott R, Mainwaring CJ. Life- thoracic injuries. Surg Clin North Am 1996; 76: 725-48. threatening bleeding in a patient with a inhibitor and probable [25] Bussieres JS. Iatrogenic pulmonary artery rupture. Curr Opin acquired factor VII deficiency. Blood Coagul Fibrinolysis 2006; Anaesthesiol 2007; 20: 48-52. 17: 667-71. [26] Karmy-Jones R, Cuschieri J, Vallieres E. Role of bronchoscopy in [40] Mann E, Kaafarani HM, Cassidy C, Chwals WJ, Jackson CC. massive hemoptysis. Chest Surg Clin N Am 2001; 11: 873-906. Spontaneous hemothorax in multiple exostoses: a case report and [27] Benumof JL, Saidman LJ, Arkin DB, Diamant M. Where review of literature. J Laparoendosc Adv Surg Tech A 2011; 21: pulmonary arterial catheters go: intrathoracic distribution. 575-7. Anesthesiology 1977; 46: 336-8. [41] Chetcuti K, Barnard J, Loggos S, et al. Massive hemothorax [28] Ganguli A, Walker L, FitzGerald RJ, Pirmohamed M. Spontaneous secondary to metastatic renal carcinoma. Ann Thorac Surg 2010; hemothorax following anticoagulation with low-molecular-weight 89: 2014-6. heparin. Ann Pharmacother 2009; 43: 1528-31. [42] Channabasavaiah AD, Joseph JV. Thoracic endometriosis: [29] Brathwaite CE, Mure AJ, O'Malley KF, Spence RK, Ross SE. revisiting the association between clinical presentation and thoracic Complications of anticoagulation for pulmonary embolism in low pathology based on thoracoscopic findings in 110 patients. risk trauma patients. Chest 1993; 104: 718-20. Medicine (Baltimore) 2010; 89: 183-8. [30] Karabulut N, Kiroglu Y. Relationship of parenchymal and pleural [43] Lin YS, Tu CY. Thoracic endometriosis. Cmaj 2011; 183: E758. abnormalities with acute pulmonary embolism: CT findings in [44] Karmy-Jones R, Vallieres E, Kralovich K, et al. A comparison of patients with and without embolism. Diagn Interv Radiol 2008; 14: rigid -v- video thoracoscopy in the management of chest trauma. 189-96. Injury 1998; 29: 655-9. [31] Light RW. Pleural effusion in pulmonary embolism. Semin Respir [45] Chemelli AP, Thauerer M, Wiedermann F, Strasak A, Klocker J, Crit Care Med 2010; 31: 716-22. Chemelli-Steingruber IE. Transcatheter arterial embolization for [32] Wick MR, Ritter JH, Schuller D. Ruptured pulmonary infarction: a the management of iatrogenic and blunt traumatic intercostal artery rare, fatal complication of thromboembolic disease. Mayo Clin injuries. J Vasc Surg 2009; 49: 1505-13. Proc 2000; 75: 639-42.

Received: September 6, 2011 Revised: November 25, 2011 Accepted: April 12, 2012