Hemothorax

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Joanna Ekabua, M.D. [2]

Hemothorax as a clinico-pathological entity can be defined in two ways. Morphologically, it is a pathologic collection of blood within the pleural cavity, between the lung surface and inner chest wall. Clinically , hemothorax is defined as a pleural fluid with a hematocrit ranging from at least 25–50% of peripheral blood. In cases of long standing haemothorax due to haemodilution, hemothorax can appear with lower levels of hematocrit. massive hemothorax is defined as the drainage of more than 1500 cc of blood upon chest tube insertion.^[1][2]

Haemothorax has been detailed in numerous medical writings dating back to ancient times. In 1794, the first intercostal incision was developed by John Hunter to treat and drainage of the hemothorax. Although Hunter’s method was effective in evacuating the hemothorax, an iatrogenic pneumothorax as a result of the procedure was significant. Some recommended closure of chest wounds without drainage. Observing the advantages and dangers of both forms of therapy, Guthrie, in the early 1800s, proposed early evacuation of blood through an existing chest wound. Finally, by the 1870s, early hemothorax evacuation by intercostal incision was considered standard practice.^[3]

Spontaneous haemothorax (SH) is a subcategory of haemothorax.^[1][4]

Haemothorax is a pathologic collection of blood within the pleural cavity, between the lung surface and inner chest wall. Three mechanisms of bleeding in haemothorax include torn adhesion between the parietal and visceral pleurae, rupture of neovascularized bullae as a complication of subpleural emphysematous blebs, and torn congenital aberrant vessels branching from the cupola and distributed in and around the bulla in the apex of the lung. There are some genetic disorder that are predisposed to haemothorax.^{[5][2][6][7][8]}

Haemothorax may be caused by trauma or can be spontaneous and iatrogenous. Causes of traumatic haemothorax include blunt force injuries ,penetrating thoracic injuries, and thoracoabdominal injuries. Causes of spontaneous haemothorax include vascular disorders, malignancies, connective tissue disorders, gynecological disorders, hematological disorders, and miscellaneous pathological entities. Haemothorax can also be a complication of various iatrogenically–related procedures. In addition, the cause of haemothorax can remain unknown even after exploratory thoracotomy.^{[9][10][2][11][6][1][12][13][14][15][16][17]}

Haemothorax must be differentiated from other diseases that cause dyspnea and respiratory distress.^{[18][19][20][21][22][23][24]}

The exact incidence of haemothorax is not clear. Chest injuries occur in approximately 60% of all polytrauma cases and haemothorax is most frequently caused by chest trauma. The occurrence of haemothorax related to trauma in the United States is estimated to be 300,000 cases annually.

Common risk factor in the development of hemothorax is trauma. Non-traumatic hemothorax is a relatively uncommon entity. Procedure can be another risk for hemothorax.

Bleeding into the pleural space is exposed to the motion of the diaphragm, lungs, and other intrathoracic structures. The agitation of cardiac and respiratory movement defibrinates the blood, and a fibrin clot thus formed is deposited on the layers of pleura. After several hours, clot formation is inevitable and it should be evacuated. if left untreated, it may progress to develop some complications.

The most common symptoms of hemothorax include severe chest pain and shortness of breath. Orthopnea can be another symptom of hemothorax.

Patients with hemothorax usually appear dullness to percussion, decreased breath sounds, tracheal deviation, and dyspnea that can be life threatening when hemodynamic instability and hypovolemic shock occurs.

Laboratory findings consistent with the diagnosis of hemothorax include reduced concentrations of hemoglobin in complete blood count (CBC) and pleural fluid with a hematocrit ranging from at least 25–50% of peripheral blood.

Radiological examination is the key for accurate identification of the source of bleeding:

• An chest x-ray may be helpful in the diagnosis of hemothorax. On chest x-ray, hemothorax is characterized by signs of occupation by pleural fluid, meniscus of fluid blunting the costophrenic angle or diaphragmatic surface and tracking up the pleural margins of the chest wall.

• Ultrasound may be helpful in the diagnosis of hemothorax. In lung ultrasound, hemothorax is diagnosed as a dependent dark zone free of echo.
• Radiological examination is the key for accurate identification of the source of bleeding. CT of the chest demonstrates pleural effusion. An enhanced chest CT scan can reveal the bleeding site and the severity of the haemothorax. It is not usually indicated in the initial trauma setting to diagnose hemothorax.

The mainstay of medical therapy for hemothorax is, fluid resuscitation and blood transfusion. All patients, regardless of causes, require attention for fluid resuscitation and blood transfusion. Prophylactic use of antibiotics following haemothorax reduces the rate of infectious complications such as pneumonia and empyema during at least 24 hours after the start of chest tube drainage. Antibiotic treatment should be directed to Staphylococcus aureus and Streptococcus species and the use of first generation cephalosporins during the first 24 hours in patients treated with chest tube drainage is recommended. Intrapleural fibrinolytic therapy (IPFT) has been advocated as an alternative to evacuate residual blood clots and breakdown adhesions in low-resource settings where the relatively costly and sophisticated technique of VATS may not be available, feasible or applicable. Several studies report on IPFT with streptokinase, urokinase or tissue plasminogen activator (TPA). Duration of treatment with IPFT can vary between 2 and 9 days for streptokinase and 2–15 days for urokinase.

The successful management of hemothorax depends on the severity of the blood loss and subsequent hemodynamic stability of the patient. The mainstay of therapy for hemothorax is intercostal chest drain (ICD) and oxygen therapy that significantly reduce the morbidity and mortality. Evacuation of haemothorax by chest tube does not succeed in all cases. The resultant retained intrapleural collections are referred to as residual hemothorax (RH). Blood in the pleural cavity may organize and fibrose, resulting in a loss of lung volume and empyema if untreated. Video assisted thoracic surgery (VATS), minimally invasive surgery has been found to be highly successful for the treatment of these residual collections, especially when used early. |VATS also can be used to treat patients with active blood loss but with stable haemodynamics, not only to stop the bleeding but also to evacuate blood clots and breakdown adhesions to prevent fibrothorax and restrictive physiology. An optimal period between the start of haemothorax and VATS of 48–72 hours is repeatedly advocated and longer intervals lead to increased rates of complications, according to some authors. A longer time span increases the chance of intraoperative conversion to thoracotomy, prolongs postoperative drainage time and is associated with a higher incidence of hospital admissions. Thoracotomy with ongoing resuscitation is the procedure of choice for patients with haemodynamic instability due to massive haemothorax or active bleeding. The criteria for thoracotomy, are blood loss by chest tube 1.500 ml in 24 h or 200 ml per hour during several successive hours and the need for repeated blood transfusions to maintain haemodynamic stability. Surgical exploration allows control of the source of bleeding and evacuation of the intrathoracic blood; and also is required for adequate empyema drainage and/or decortication.

There is no established method for prevention of hemothorax. However, early and adequate treatment which prevents of complication (suppuration) is necessary. Some factors which most frequently promote suppuration of the thoracic cavity, developing from traumatic haemothorax. so, attention is called to secure the necessary personal and material conditions to the preventive treatment.

Secondary prevention strategies following hemothorax include medical therapy and surgical therapy.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Irfan Dotani

Haemothorax has been detailed in numerous medical writings dating back to ancient times. In 1794, the first intercostal incision was developed by John Hunter to treat and drainage of the hemothorax. Although Hunter’s method was effective in evacuating the hemothorax, an iatrogenic pneumothorax as a result of the procedure was significant. Some recommended closure of chest wounds without drainage. Observing the advantages and dangers of both forms of therapy, Guthrie, in the early 1800s, proposed early evacuation of blood through an existing chest wound. Finally, by the 1870s, early hemothorax evacuation by intercostal incision was considered standard practice.^[1]

Important dates in the history of hemothorax:^[1]

• In 1794, the first intercostal incision was developed by John Hunter to treat and drainage of the hemothorax.
• Guthrie, in the early 1800s, proposed early evacuation of blood through an existing chest wound.
• By the 1870s, early hemothorax evacuation by intercostal incision was considered standard practice.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Irfan Dotani Joanna Ekabua, M.D. [2]

Spontaneous haemothorax (SH) is a subcategory of haemothorax.^[1][2]

Hemothorax may be classified as^[1][2]

• Traumatic haemothorax
• Spontaneous haemothorax
• Iatrogenous haemothorax

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Irfan Dotani Joanna Ekabua, M.D. [2]

Haemothorax is a pathologic collection of blood within the pleural cavity, between the lung surface and inner chest wall. Three mechanisms of bleeding in haemothorax include torn adhesion between the parietal and visceral pleurae, rupture of neovascularized bullae as a complication of subpleural emphysematous blebs, and torn congenital aberrant vessels branching from the cupola and distributed in and around the bulla in the apex of the lung. There is some genetic disorder that is predisposed to haemothorax.^{[1][2][3][4][5]}

The pathogenesis of hemothorax include^{[1][2][3][4][5]}

Three mechanisms of bleeding in haemothorax:

• Torn adhesion between the parietal and visceral pleurae.
• Rupture of neovascularized bullae as a complication of subpleural emphysematous blebs.
• Torn congenital aberrant vessels branching from the cupola and distributed in and around the bulla in the apex of the lung.

• Ehlers-Danlos syndrome (EDS) forms part of a spectrum of genetically based connective tissue disorders that includes osteogenesis imperfecta. Vascular Ehlers-Danlos syndrome (EDS IV) is characterized by an alteration in the COL3A1 gene. This gene encodes type III collagen and The alteration of this type of collagen produces aneurysms and ruptures of vessels and organs that can lead to haemothorax.

• Osler–Weber–Rendu disease, also known as hereditary hemorrhagic telangiectasia (HHT), is an autosomal dominant disease characterized by multiple cutaneous, systemic, and/or pulmonary arteriovenous malformations (AVMs). Bleeding from pulmonary lesions usually occur as hemoptysis and rarely as spontaneous haemothorax. There is an association between Osler-Weber-Rendu disease and bilateral heterochronic spontaneous hemothorax.

• Coastal exostosis or Osteochondroma is an autosomal dominant hereditary abnormality and the most common benign thoracic bone tumor. It often presents singly or in multiple sites that can cause laceration of the lung and hemothorax.

• Hemophilia A is a X-linked hereditary disorder of blood clotting that caused by the development of an inhibitor against coagulation factor VIII (FVIII). Hemophilia A manifests with early muscle and subcutaneous bleeding and rarely with haemothorax.

• Glanzmann thromboastenia is an autosomal-recessive bleeding disorder characterized by a lifelong bleeding tendency due to abnormalities of the platelet integrin αΠbβ3 [[[glycoprotein]] (GP) IIb; CD41/IIIa; CD61]. Glanzmann thromboastenia usually presents with mucocutaneous bleeding such as easy bruising, purpura, gingival bleeding, epistaxis, menorrhagia, haemarthrosis, haematuria, intracranial and visceral hemorrhage are rare but even rarer is Spontaneous Haemothorax.

• Type I neurofibromatosis (NF-1) or Von Recklinghausen’s disease (VRD) is an autosomal dominant disease. This entity can affect any organ system and is characterized by skin tumors and abnormal cutaneous pigmentation. Pathogenetic mechanisms for vasculopathy associated with VRD are: (I) direct vascular invasion from adjacent tumors; and (II) vascular dysplasia with thickening and concomitant reduced the strength of the vessel wall and an aneurysm formation.
• There are other hereditary entities such as Loeys–Dietz syndrome, familial thoracic aortic aneurysm syndrome, or Shprintzen–Goldberg syndrome that are predisposed to aortic dissection and haemothorax.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Irfan Dotani Joanna Ekabua, M.D. [2]

Haemothorax may be caused by trauma or can be spontaneous and iatrogenic. Causes of traumatic haemothorax include blunt force injuries, penetrating thoracic injuries, and thoracoabdominal injuries. Causes of spontaneous haemothorax include vascular disorders, malignancies, connective tissue disorders, gynecological disorders, hematological disorders, and miscellaneous pathological entities. Haemothorax can also be a complication of various iatrogenically–related procedures. In addition, the cause of haemothorax can remain unknown even after exploratory thoracotomy.^{[1][2][3][4][5][6][7][8][9][10][11][12]}

Common causes of hemothorax include.^{[1][2][3][4][5][6][7][8][9][10][11][12]}

Chest trauma is of three types:

• Blunt force injury cases such as those that occur in vehicular collisions and following falls or jumps from heights
• Penetrating thoracic injuries produced by a stab or gunshot wounds
• Thoracoabdominal injuries

Spontaneous haemothorax is a rare clinical condition in the absence of trauma or iatrogenic causes. Bilateral spontaneous haemothorax is a very rare entity and the main cause of it is primary or metastatic pleural angiosarcoma. Causes of spontaneous haemothorax include:

• Vascular disorders causing spontaneous hemothroax include aortic aneurysm rupture, rupture of thoracic aortic dissection – dissection is due to arterial hypertension followed by atherosclerosis -, rupture of a saccular aortic aneurysm and traumatic rupture of the pericardial sac during cardiopulmonary resuscitation in individuals with hemopericardium, fatal spontaneous dissection of supra-aortic vessels without any evidence of aortic disease during pregnancy and early puerperium, bronchial artery aneurysm rupture, aneurysmatic internal thoracic artery, intercostal vessels, internal thoracic artery aneurysm, or pulmonary congenital aberrant vessels, ruptured mycotic aneurysms, innominate truncal dissection, using neck veins for mainlining and rupture of a subclavian artery aneurysm, pulmonary arteriovenous malformations (AVMs), fatal and non-fatal AVM-associated massive hemothorax is often linked to Osler–Weber–Rendu disease, associated with congenital heart disease such as rupture of a patent ductus arteriosus, Eisenmenger syndrome, aortic coarctation and bicuspid aortic valve disease.

• Malignancies causing spontaneous hemothroax include lymphangiosarcoma and vascular mediastinal schwannoma, schwanommas of von Recklinghausen disease, lymphangioma, mediastinal teratoma, metastatic choriocarcinoma, metastatic renal carcinoma, Abrikossoff tumor, pulmonary angiosarcoma, osteochondroma, Kaposiform endodermal sinus tumour, hemangioendothelioma, hemangioma, hemangiopericytoma fibrous tumor of the pleura, hepatocellular carcinoma, periosteal chondroma, chondroblastoma of the rib, synovial sarcoma, osteosarcoma, Ewing sarcoma, neurofibrosarcoma, thymoma, mediastinal meningioma, thoracic neuroblastoma, pleural mesothelioma, chronic myeloid leukaemia, neurofibromatosis type I (Morbus von Recklinghause), chondrosarcomas, ectopic meningioma and germ cells tumors.

• Connective tissue disorders causing spontaneous hemothorax include Vascular Ehlers–Danlos syndrome (Ehlers–Danlos type IV, EDS IV), Marfan syndrome, Loeys–Dietz syndrome, familial thoracic aortic aneurysm syndrome, Shprintzen–Goldberg syndrome and Type I neurofibromatosis (NF-1) or Von Recklinghausen’s disease (VRD).

• Pleural disorders causing spontaneous hemothorax include spontaneous pneumothorax, spontaneous pneumohemothorax (the accumulation of >400 mL of blood in the pleural cavity in association with spontaneous pneumothorax) and pleural metastasis.

• Coastal exostoses or osteochondroma occurs either sporadically or as a manifestation of a genetic disorder known as hereditary multiple exostoses (HME). Lesions mainly occur in infants and children and their complications include haemothorax, pneumothorax, diaphragmatic or pericardial lacerations and visceral pleural injury.

• Gynecological disorders causing spontaneous hemothorax include Intrathoracic implantation of ectopic endometrial tissue occurs as a result of the migration of endometrial tissue through the thoracic diaphragm. Spontaneous haemothorax may be a response to cyclical hormonal changes in menstruating women.

• Hematological disorders causing spontaneous hemothroax include hemophilia, immune-mediated platelet destruction due to Many drugs such as sedatives, tranquilizers, anticonvulsants, and heparin, anticoagulant-associated hemothorax, specifically, as a result of thromboembolic disease treatment, hematology-related hemothorax include Glanzmann’s thrombasthenia, thrombotic thrombocytopenic purpura, and intrathoracic extramedullary hematopoiesis, intrathoracic intramedullary hematopoiesis due to a secondary process, such as myeloproliferative disorders, hemolytic anemia, hereditary spherocytosis, chronic asthma, and Gaucher disease, beta thalassemia, rupture of extramedullary hematopoietic pulmonary nodules, haemothorax has been also reported in the setting of plasminogen activator user for venous thrombosis in patient with pneumonia.

• Miscellaneous causing spontaneous hemothroax include tuberculosis, necrotizing lung infection, uremia, spontaneous hemothorax secondary to a ruptured parasitic hydatid (Echinococcal) cyst of pulmonary parenchyma, Malaria is another rare parasitic etiology for spontaneous hemothorax, amyloidosis-induced spontaneous mediastinal hemorrhage with hemothorax due to perivascular and vascular wall involvement, systemic diseases like systemic lupus erythematosus (SLE) and Henoch-Schönlein purpura, pulmonary emboli, ectopic pregnancy, Extralobar pulmonary sequestration (EPS).
• In some patients the cause can remain unknown even after exploratory thoracotomy.

Iatrogenous haemothorax may be caused by either intrathoracic vessel cannulation, chest drain insertion, needle thoracocentesis, pleural or lung biopsies, closed-chest cardiopulmonary resuscitation, placement of subclavian- or jugular-catheters, endoscopic thoracic interventions, cardiopulmonary surgery, sclerotherapy of oesophageal varices, rupture of pulmonary arteries after placement of Schwann–Ganz catheters, thoracic sympathectomy or translumbar aortography. surgical procedures such as releasing the pleurae from the vertebrae, or the removal and curettage of intervertebral discs and cartilage end plates.

Template:WH Template:WS

Joanna Ekabua, M.D. [1]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Irfan Dotani

Haemothorax must be differentiated from other diseases that cause dyspnea and respiratory distress.^{[1][2][3][4][5][6][7]}

Hemothorax must be differentiated from ^{[1][2][3][4][5][6][7]}

• Chylothorax
• Pleural effusion
• Pneumothorax
• Hydrothorax
• Hemothorax
• Cardiac tamponade

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Irfan Dotani Joanna Ekabua, M.D. [2]

The exact incidence of hemothorax is not clear. Chest injuries occur in approximately 60% of all polytrauma cases and haemothorax is most frequently caused by chest trauma. The occurrence of hemothorax related to trauma in the United States is estimated to be 300,000 cases annually.^[1]

• Chest injuries occur in approximately 60% of all polytrauma cases and hemothorax is most frequently caused by chest trauma.^[1]
• The occurrence of hemothorax related to trauma in the United States is estimated to be 300,000 cases annually.^[1]

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Irfan Dotani Joanna Ekabua, M.D. [2]

The common risk factor in the development of hemothorax is trauma. Non-traumatic hemothorax is a relatively uncommon entity. The procedure can be another risk for hemothorax.^{[1][2][3][4][5]}

Common risk factors in the development of hemothorax include^{[1][2][3][4][5][6][7]}

• Thoracic trauma
• Thoracic surgery
• Thoracentesis
• Iatrogenous causes
• Thoracic endometriosis

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Joanna Ekabua, M.D. [2]

There is insufficient evidence to recommend routine screening for hemothorax.

There is insufficient evidence to recommend routine screening for hemothorax.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Irfan Dotani Joanna Ekabua, M.D. [2]

Please help WikiDoc by adding more content here. It’s easy! Click here to learn about editing.

Bleeding into the pleural space is exposed to the motion of the diaphragm, lungs, and other intrathoracic structures. The agitation of cardiac and respiratory movement defibrinates the blood, and a fibrin clot thus formed is deposited on the layers of pleura. After several hours, clot formation is inevitable and it should be evacuated. if left untreated, it may progress to develop some complications.

Bleeding into the pleural space is exposed to the motion of the diaphragm, lungs, and other intrathoracic structures. The agitation of cardiac and respiratory movement defibrinates the blood, and a fibrin clot thus formed is deposited on the layers of pleura. Within several hours of cessation of bleeding, clot formation is inevitable and it will be difficult to remove. The membrane continues to thicken by progressive deposition, so the clotted haemothorax should be evacuated within a reasonable time after the onset of bleeding. Chronic and retained hemothorax may progress to develop respiratory distress, lung entrapment with impaired pulmonary function, retained clot, chronic fibrothorax, empyema and extended hospitalization if left untreated.^{[1][2][3][4][5]}

Common complications of hemothorax includeref name^{[2][3][5][6][7]}

• Respiratory distress
• Lung entrapment
• Impaired pulmonary function
• Retained clot
• Chronic fibrothorax
• Empyema
• Extended hospitalization
• Atelectasis
• Pneumonia

The morbidity and mortality rate of hemothorax correlates with the cause and the severity of the injury. Patients with retained hemothorax are at higher risk of developing empyema leading to prolonged Intensive care unit/hospital stay.^[8]

Template:WH Template:WS