Hemothorax

Hemorrhage into the pleural cavity is a common complication of closed or open chest injury. Most often, hemothorax occurs due to ruptures of the vessels of the chest wall or lung. The volume of hemorrhage can reach two liters or more.

In case of extensive hemothorax, the integrity of the intercostal arteries is most often recorded as being compromised, less often – the aorta or other large vessels of the chest. This condition is considered dangerous, first of all, due to progressive compression of the lung and development of respiratory failure, as well as due to massive blood loss.

ICD 10 code

• J00-J99 Diseases of the respiratory system;
• J90-J94 Other pleural diseases;
• J94 Other pleural disorders;
• J94.2 Hemothorax.
• S27.1 Traumatic hemothorax.

Causes of hemothorax

Etiologically, haemothorax is divided into the following types:

• traumatic (occurs as a result of penetrating injuries or after a closed chest injury);
• pathological (develops as a result of various internal pathologies);
• iatrogenic (occurs as a consequence of surgery, pleural puncture, insertion of a catheter into the central venous vessels, etc.).

There is a whole list of diseases and situations that in most cases can cause bleeding into the pleural cavity. Among them:

• chest wounds (gunshot or knife);
• thoracic injuries;
• rib fracture;
• compression fractures;
• aortic aneurysm;
• pulmonary tuberculosis;
• oncology of the lung, pleura, mediastinal organs or thoracic region;
• lung abscess;
• impaired blood clotting (coagulopathy, hemorrhagic diathesis);
• consequences of lung surgery;
• thoracocentesis;
• drainage of the pleural cavity;
• placement of a catheter in the central venous vessels.

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Symptoms of hemothorax

Minor hemothorax may not be accompanied by any special complaints in patients. Percussion reveals a shortened sound on the Damoiseau line. Listening reveals weakness of respiratory movements in the posterior lower parts of the lung.

With severe hemothorax there are signs of acute internal bleeding:

• pale skin;
• the appearance of cold sweating;
• increased heart rate;
• lowering blood pressure.

Symptoms of acute respiratory failure gradually increase. Percussion examination reveals a dull sound in the middle and lower regions of the lung. Listening reveals a cessation or sudden weakness of respiratory sounds. Patients complain of a feeling of heaviness in the chest, a lack of air, and the inability to take a full, complete breath.

Hemothorax in children

In childhood, damage to large-caliber vessels is extremely rare, since penetrating injuries in children are a rare occurrence. But the condition of hemothorax in a child can also appear as a result of a rib fracture with a violation of the integrity of the intercostal arteries.

Experimental modeling of hemothorax has shown that massive bleeding into the pleural cavity causes a decrease in blood pressure. In this regard, parents should be especially attentive so as not to miss important symptoms and provide timely assistance to their child. The first signs of internal hemorrhage may be: difficulty breathing, pale or blue skin, wheezing sounds when inhaling. What can relatives do in this situation? Apply cold to the chest area and immediately call an ambulance.

When providing assistance to children, it is important to quickly provide venous access, since rapid pumping of blood from the pleural cavity often leads to a decrease in the volume of circulating blood and even to cardiac arrest.

If a child has suffered a chest injury, at the same time as the pressure began to decrease, and there are no symptoms of visible bleeding, haemothorax should be suspected and appropriate resuscitation measures should be carried out.

Classification

Hemothorax has several classification options. For example, degrees are distinguished depending on the severity of bleeding in the pleural cavity:

• minor bleeding (or minor haemothorax) – the amount of blood loss does not reach 0.5 l, there is an accumulation of blood in the sinus;
• moderate bleeding – blood loss up to one and a half liters, the blood level is determined below the fourth rib;
• subtotal degree – blood loss can reach 2 liters, the blood level can be determined up to the lower border of the second rib;
• total degree of bleeding – the amount of blood loss is more than 2 liters, the X-ray shows total darkening of the cavity on the affected side.

The classification of the disease according to its course is also known.

• Coagulated - observed after surgical operations, when the patient undergoes coagulant therapy. As a result of this therapy, the patient's blood coagulability increases, which is why the blood that enters the pleural cavity coagulates.
• Spontaneous – observed extremely rarely. Characterized by spontaneous, unexpected hemorrhage in the pleural cavity. The causes of such pathology have not yet been established.
• Pneumo hemothorax is a combined pathology when not only blood but also air accumulates in the pleural cavity. This condition often occurs when a lung ruptures or when a tuberculous lesion melts.
• Traumatic – develops as a result of some kind of trauma, after penetrating injuries or closed chest trauma. Most often observed with rib fractures.
• Left-sided - this is a hemorrhage in the pleural cavity on the left lobe of the lung.
• Right-sided - this is the outpouring of blood into the pleural cavity from the right lung. By the way, unilateral haemothorax on any side leads to acute respiratory failure, which is a direct threat to the patient's life.
• Bilateral – implies damage to both the right and left lungs. This condition is extremely unfavorable and is considered to be absolutely fatal within one or two minutes of its appearance.

Depending on the complexity of the condition, a distinction is made between uninfected and infected hemothorax, which is determined by the presence of infection in the pleural cavity.

Also, in the dynamic aspect, the disease is divided into two types: progressive course and stable course of hemothorax.

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Diagnostics

Diagnostic tests used when pneumothorax is suspected can be either laboratory or instrumental. The most common of them are the following:

• X-ray examination;
• ultrasound scanning technique of the pleural cavity;
• computer and magnetic resonance imaging techniques;
• bronchoscopic examination with simultaneous biopsy;
• sputum cytology;
• performing thoracentesis with Petrov or Rivilois-Gregoire tests.

Pleural puncture can be used as a diagnostic and therapeutic measure. Puncture for hemothorax is a puncture in the chest wall and the membrane covering the lungs. This is one of the simplest and most accessible interventions, which in many situations helps to save the victim's life.

During radiography, it is possible to detect symptoms of a separate form of pathology - in most cases, this is typical for patients with adhesive changes in the pleural cavity. Isolated haemothorax is determined as a delineated darkening with a uniform structure in the middle and lower regions of the lung.

A more informative procedure is thoracentesis with the collection of contents from the pleural cavity. This study is performed to establish ongoing hemorrhage or symptoms of pleural infection. At the same time, a test is performed for hemothorax:

• Petrov's test helps to detect a deterioration in the transparency of the blood taken, which may indicate the presence of an infection;
• The Rivilois-Gregoire test allows one to detect signs of clotting of the extracted blood.

However, the most informative method is considered to be thoracoscopy, which is performed only if there are serious indications. This is an endoscopic procedure that allows you to examine the inner surface of the pleural cavity.

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First aid

First aid for hemothorax should include the following actions:

• calling an emergency team;
• placing the victim in an elevated position with the head of the bed raised;
• applying cold to the affected area of the chest.

If possible, a 50% solution of analgin can be administered in the amount of 2 ml intramuscularly, as well as cardiovascular drugs (cordiamine or sulfocamphocaine, 2 ml subcutaneously).

First aid upon arrival of doctors consists of oxygen therapy, pain relief. Anti-shock measures may be carried out:

• applying a tight bandage;
• vagosympathetic novocaine block;
• intravenous administration of glucose solution (40%), ascorbic acid (5%);
• intramuscular administration of hydrocortisone in an amount of up to 50 mg;
• intravenous administration of 10% calcium chloride.

In case of hypovolemia symptoms, Rheopolyglucin is urgently administered in the amount of 400 ml intravenously by drip. If the patient's delivery to the hospital is delayed, then a pleural puncture is performed in the 7th intercostal space along the scapular border and the spilled blood is aspirated.

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Treatment of hemothorax

Treatment of the victim can be carried out by specialists of various specialties - surgeons, rehabilitation specialists, pulmonologists, etc.

The effectiveness of treatment depends directly on the timeliness of pathology recognition and competent emergency care. Of course, treatment should be started as soon as possible, since, in addition to the development of respiratory failure, infection of the spilled blood may occur, which is considered an extremely unfavorable factor.

Conservative treatment using antimicrobial and anti-inflammatory drugs is prescribed only for a low degree of hemothorax, in the absence of significant dysfunction of the patient's organs and systems. Treatment is carried out exclusively under the supervision of a specialist with constant control radiography. The most acceptable period, sufficient for the resorption of the spilled blood, is considered to be a period of 14 days to a month. In order to accelerate resorption, I recommend that patients receive injections of proteolytic enzymes (for example, Chymotrypsin 2.5 mg intramuscularly daily for 15 days), as well as direct treatment of the pleural cavity with Urokinase and Streptokinase liquids.

Patients with other degrees of haemothorax should be urgently taken to a medical facility where they will undergo pleural puncture. This manipulation is carried out in the area of the sixth to seventh intercostal space, observing all the principles of asepsis. The spilled blood is sucked out, and antimicrobial solutions are introduced instead.

If pleural puncture does not improve the patient's condition, emergency thoracoscopy or thoracotomy is indicated.

Thoracotomy for hemothorax is a surgical incision with penetration into the empyema cavity. This operation can be simple (with an incision in the intercostal space) or resection (with removal of part of the rib). Simple thoracotomy is performed in the 7th or 8th intercostal space at the level of the posterior axillary line. Drainage for hemothorax is performed after resection of a small costal area (about three centimeters), cutting a special opening in the pleura according to the diameter of the installed drainage.

A sufficiently large drainage tube is carefully inserted into the cavity, the lower part of which (the free end) is lowered into a container with liquid. This is done to create a closed siphon system, which will ensure the outflow of blood or other liquids. In early childhood, thoracotomy can be performed without drainage.

Prognosis and prevention

Preventive measures include preventing chest injuries and mandatory consultation of victims with thoracoabdominal wounds by pulmonary surgeons. It is necessary to control hemostasis during surgical interventions in the lungs and mediastinal organs, as well as to perform invasive procedures competently and carefully.

The prognosis of hemothorax depends on how severe the lesion of the chest and adjacent organs is, as well as on the volume of blood loss and the adequacy of emergency care measures. In addition, the effectiveness of treatment may depend on the nature of the injury (unilateral or bilateral hemorrhage). A more optimistic prognosis is determined with a small and moderate degree of hemothorax. The coagulated form increases the risk of pleural empyema. The consequences of hemothorax, accompanied by prolonged or one-time large bleeding, are the most pessimistic, up to the patient's death.

If the treatment was provided in a timely and competent manner, then the prognosis is usually favorable. During the rehabilitation period, patients are recommended to start swimming, race walking, and perform special breathing exercises to prevent the formation of adhesions in the pleura, which can significantly affect the function of the diaphragmatic dome. It is important to understand that hemothorax is a very serious condition, and the recovery period can be quite long.