Hemothorax: Symptoms, Treatment, Causes

2024 Author: Rachel Wainwright | [email protected]. Last modified: 2023-12-15 07:39

Hemothorax

The content of the article:

1. Causes
2. Forms
3. Signs
4. Diagnostics
5. Treatment
6. Consequences and complications

Hemothorax is an accumulation of blood in the pleural cavity (from ancient Greek αíμα - "blood" and θώραξ - "chest").

Normally, the pleural cavity is limited by two layers of the pleura: parietal, lining the walls of the chest cavity and mediastinal structure from the inside, and visceral, which covers the lungs. The pleural cavity contains several milliliters of serous fluid, which provides smooth, frictionless, sliding of the pleura during the respiratory movements of the lungs.

Signs of hemothorax

With various pathological conditions and injuries, blood is poured into the pleural cavity - from tens of milliliters to several liters (in especially severe cases). In this situation, they talk about the formation of hemothorax.

Descriptions of this pathological condition are found at the dawn of the formation of surgery (XV-XVI centuries), but the first substantiated recommendations for the treatment of hemothorax, formulated by NI Pirogov, appeared only at the end of the XIX century.

Causes

Most often, hemothorax is traumatic: blood accumulates in the pleural cavity in 60% of cases of penetrating chest wounds and in 8% of cases of non-penetrating injuries.

The main causes of hemothorax:

• knife and gunshot wounds;
• blunt bruised wounds leading to rupture of blood vessels (including intercostal);
• fractures of the ribs with damage to the lung tissue;
• pulmonary tuberculosis;
• rupture of the aortic aneurysm;
• malignant processes of the lungs, pleura, mediastinal organs (germination of neoplasms into the vessels);
• lung abscess;
• complications after surgery on the organs of the mediastinum and lungs;
• thoracocentesis;
• diseases of the coagulation system;
• incorrectly performed central venous catheterization;
• drainage of the pleural cavity.

After the outflow of blood into the pleural cavity under the influence of hemostasis factors, it coagulates. Subsequently, as a result of activation of the fibrinolytic link of the coagulation system and mechanical action caused by the respiratory movements of the lungs, the coagulated blood "unfolds", although sometimes this process is not carried out.

Hemothorax from chest injury, x-ray

Blood entering the pleural cavity compresses the lung on the affected side, provoking respiratory dysfunction. In case of progression of hemothorax, the mediastinal organs (heart, large aortic, venous, lymphatic and nerve trunks, trachea, bronchi, etc.) are displaced to the healthy side, acute hemodynamic disturbances develop, respiratory failure increases due to the involvement of the second lung in the pathological process.

Forms

Depending on the defining criterion, hemothorax is classified according to several criteria.

For a causal factor, it happens:

• traumatic;
• pathological (resulting from the underlying disease);
• iatrogenic (provoked by medical or diagnostic manipulations).

By the presence of complications:

• infected;
• uninfected;
• coagulated (unless the reverse "unfolding" of the blood poured out).

In accordance with the volume of intrapleural bleeding:

• small (volume of blood loss - up to 500 ml, accumulation of blood in the sinus);
• medium (volume - up to 1 liter, the blood level reaches the lower edge of the IV rib);
• subtotal (blood loss - up to 2 liters, blood level - to the lower edge of the II rib);
• total (blood loss - more than 2 liters, total darkening of the pleural cavity on the side of the lesion is determined radiographically).

Depending on the dynamics of the pathological process:

• growing;
• non-growing (stable).

If blood in the pleural cavity accumulates in an isolated area within the interpleural adhesions, they speak of limited hemothorax.

Given the localization, limited hemothorax can be of the following types:

• apical;
• interlobar;
• paracostal;
• supraphrenic;
• paramediastinal.

If, in parallel with bleeding, air enters the pleural cavity, hemopneumothorax develops.

Signs

With a small hemothorax, the patient is quite active, may feel satisfactory or complain of slight shortness of breath, a feeling of respiratory discomfort, and coughing.

With an average hemothorax, the clinic is more pronounced: a state of moderate severity, intense shortness of breath, aggravated by physical exertion, chest congestion, intense cough.

Middle hemothorax is manifested by chest pain, shortness of breath, intense cough

Subtotal and total hemothorax have similar manifestations, differing in severity:

• severe, sometimes extremely serious condition, which is determined by a combination of respiratory failure and hemodynamic disturbances due to not only compression of large vessels of the mediastinum, but also massive blood loss;
• cyanotic staining of the skin and visible mucous membranes;
• severe shortness of breath with minor physical exertion, changes in body position, at rest;
• frequent threadlike pulse;
• severe hypotension;
• chest pain;
• harsh painful cough;
• forced position with a raised headboard, as suffocation develops in the prone position.

Diagnostics

The main diagnostic measures:

• objective examination of the patient (for the presence of wounds, trauma, the establishment of a characteristic percussion and auscultatory picture);
• X-ray examination;
• magnetic resonance imaging or computed tomography (if necessary);
• puncture of the pleural cavity with subsequent examination of the punctate for infection (Petrov's test);
• performing the Ruvilua-Gregoire test (differential diagnosis of ongoing or stopped bleeding).

Puncture of the pleural cavity if hemothorax is suspected

Treatment

Treatment of hemothorax includes the following measures:

• treatment of a chest wound and suturing (in case of minor damage, and if internal organs are involved in a massive injury, thoracotomy is performed);
• drainage of the pleural cavity to remove blood;
• replenishment of the circulating blood volume (with massive blood loss);
• antibiotic therapy (in case of hemothorax infection);
• anti-shock therapy (if necessary).

Consequences and complications

Complications of hemothorax are very serious:

• hypovolemic shock;
• acute heart failure;
• acute respiratory failure;
• sepsis;
• fatal outcome.

Olesya Smolnyakova Therapy, clinical pharmacology and pharmacotherapy About the author

Education: higher, 2004 (GOU VPO "Kursk State Medical University"), specialty "General Medicine", qualification "Doctor". 2008-2012 - Postgraduate student of the Department of Clinical Pharmacology, KSMU, Candidate of Medical Sciences (2013, specialty "Pharmacology, Clinical Pharmacology"). 2014-2015 - professional retraining, specialty "Management in education", FSBEI HPE "KSU".

The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!