Hemotorax

Hemorrhage into the pleural cavity is a common type of complication of closed or open chest damage. Most often, hemothorax (haemothorax) appears due to rupture of the vessels of the chest wall or lung. The amount of hemorrhage in this case is able to reach two liters and even more.

With extensive hemothorax, breach of the integrity of intercostal arteries is more often detected, more rarely - aorta or other volumetric vessels of the breast. This condition is considered dangerous, primarily due to the progressive squeezing of the lung and the development of respiratory failure, and also because of massive blood loss.

ICD Code 10

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

Causes of hemothorax

Etiologically, haemothorax is divided into these types:

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

It is possible to single out a whole list of diseases and situations, which in most cases can become the cause of the flow of blood into the pleural cavity. Among them:

• injured breasts (gunshot or knife);
• thoracic trauma;
• fracture of rib;
• compression fractures;
• aortic aneurysm;
• pulmonary form of tuberculosis;
• oncology of the lung, pleura, mediastinal organs or thoracic department;
• abscess of the lungs;
• impaired blood coagulability (coagulopathy, hemorrhagic diathesis);
• consequences of pulmonary surgery;
• thoracocentesis;
• drainage of the pleural cavity;
• catheter placement on the central venous vessels.

[1], [2], [3], [4], [5], [6]

Symptoms of hemothorax

Minor hemothorax may not be accompanied by special complaints in patients. During percussion, there is a shortening of sound on the line of Damoiso. At listening - weakness of respiratory movements in the posterior parts of the lung.

With expressed hemothorax, there are signs of acute internal hemorrhage:

• pale skin;
• the appearance of cold sweating;
• cardiopalmus;
• lowering of blood pressure.

Gradually, the symptoms of acute respiratory failure increase. With percussion examination, a dull sound is observed in the middle and lower regions of the lung. When listening, noticeably the cessation or sudden weakness of respiratory noises. Patients complain of a feeling of heaviness in the chest, a shortage of air and the inability to make a full breath.

Hemotorax in children

In childhood, the damage of large calibrated vessels is extremely rare, since penetrating trauma in children is not a frequent occurrence. But the state of hemothorax in a child may appear due to fracture of the ribs with violation of the integrity of the intercostal arteries.

Experimental modeling of hemothorax showed that massive bleeding into the pleural cavity provokes lowering of blood pressure. In this regard, parents should be particularly careful not to miss important symptoms and help their child in time. The first signs of internal hemorrhage may be: shortness of breath, blanching or blueness of the skin, wheezing sounds during inspiration. What can close people do in this situation? Apply cold to the chest area and immediately call an ambulance.

When providing care to children, an important point is the rapid provision of venous access, since the rapid evacuation of blood from the pleural cavity often leads to a decrease in the volume of circulating blood and even to the arrest of cardiac activity.

If the child has a chest injury, simultaneously with which the pressure began to decrease, and symptoms of visible bleeding are not observed - it is necessary to suspect haemothorax and to carry out appropriate resuscitation measures.

Classification

Hemotorax has several variants of classifications. For example, degrees are divided, depending on the severity of bleeding in the pleural cavity:

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

There is also a classification of the disease according to its course.

• Collapsed - is observed after surgical operations, when the patient is coagulant therapy. As a result of this therapy, the patient's blood coagulability increases, which causes the blood that gets into the pleural cavity to collapse.
• Spontaneous - is extremely rare. It is characterized by spontaneous unanticipated hemorrhage in the pleural cavity. The causes of this 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 happens when the lung is ruptured or when the tubercle focus is melted.
• Traumatic - develops due to any injury, after penetrating injuries or closed traumatism of the chest. Most often observed with fractures of the ribs.
• Left-sided is a hemorrhage in the pleural cavity from the left lobe of the lung.
• Right-sided is the discharge of blood into the cavity of the pleura from the right lung. By the way, unilateral haemothorax from either side leads to acute insufficiency of the respiratory function, which poses a direct threat to the life of the patient.
• Two-sided - involves damage to both the right and left lungs. This condition is extremely unfavorable, and is considered unconditionally fatal already within one or two minutes after the appearance.

According to the complexity of the condition, uninfected and infected hemothorax is isolated, which is determined by the presence of infection in the pleural cavity.

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

[7], [8], [9], [10], [11]

Diagnostics

Diagnostic tests used for suspected pneumothorax can be both laboratory and instrumental. The most common are the following:

• X-ray examination;
• ultrasound scanning of the pleural cavity;
• computer and magnetic resonance imaging;
• bronchoscopic examination with simultaneous biopsy;
• Sputum cytology;
• carrying out a thoracocentesis with Petrov or Rivilua-Gregoire.

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

During radiography, it is possible to detect the 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 defined as a delineated shade with a uniform structure in the middle and lower regions of the lung.

A more informative procedure is a pleurocentesis with taking contents from the pleural cavity. This research is being conducted to establish an ongoing hemorrhage or symptoms of pleural infection. Simultaneously, a sample is taken with hemothorax:

• Petrova's test helps to detect a deterioration in the transparency of the blood taken, which may indicate the presence of infection;
• The Rivilua-Gregoire test reveals signs of folding of seized blood.

Nevertheless, the most informative technique is thoracoscopy, which is performed only if there are serious indications. This is an endoscopic procedure that allows you to view the inner surface of the pleural cavity.

[12], [13], [14], [15], [16], [17], [18]

First aid

First aid for hemothorax should consist of the following:

• call the "emergency aid" brigade;
• giving the victim an elevated position with an elevated headboard;
• Applying cold to the affected area of the chest.

If possible, you can enter a 50% solution of analgin in the amount of 2 ml IM, as well as cardiovascular drugs (cordiamine or sulphocamphocaine in 2 ml of SC).

The first help on the arrival of doctors is in oxygen therapy, anesthesia. Possible anti-shock measures:

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

With symptoms of hypovolemia, Rapoliglyukin is promptly administered in an amount of 400 ml IV / IV. If the patient's delivery to the hospital is delayed, then pleural puncture is performed in the VII intercostal space along the scapula and aspirated blood is spilled.

[19], [20], [21]

Treatment of hemothorax

Treatment of the injured can be carried out by specialists of various orientations: surgeons, rehabilitation specialists, pulmonologists, etc.

The effectiveness of therapeutic actions is directly dependent on the timeliness of pathology recognition and correctly rendered emergency care. Of course, treatment should be started as soon as possible, because, in addition to the development of respiratory insufficiency, there can be an infection of the bleeding blood, which is considered an extremely unfavorable factor.

Conservative treatment using antimicrobial and anti-inflammatory drugs is prescribed only with a small degree of hemothorax, in the absence of significant disturbances in the functions of the organs and systems of the patient. Treatment is carried out exclusively under the supervision of a specialist with a continuous monitoring radiograph. The most acceptable period, sufficient for resorption of blood, is the period from 14 days to a month. In order to speed up resorption, patients are advised to inject proteolytic enzymes (for example, Chymotrypsin 2.5 mg IM daily for 15 days), as well as direct treatment of the pleural cavity with liquids Urokinase, Streptokinase.

Patients with other degrees of haemothorax should be rushed to the hospital, where they will undergo pleural puncture. Such manipulation is carried out in the area of the sixth-seventh intercostal space with observance of all principles of asepsis. Spilled blood is sucked off, and antimicrobial solutions are introduced in return.

If a pleural puncture does not lead to relief of the patient's condition, an emergency thoracoscopy or thoracotomy is indicated.

Thoracotomy with hemothorax is a surgical incision with penetration into the empyema cavity. This operation can be simple (with a cut in the intercostal space) or resection (with the removal of part of the rib). Simple thoracotomy is performed in the VII or VIII intercostal space at the level of the back axillary line. Draining with hemothorax is performed after resection of a small rib portion (about three centimeters), cutting a special hole in the pleura according to the diameter of the drainage to be installed.

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

Prognosis and prevention

Preventative measures are to prevent injuries of the chest, as well as in mandatory counseling of victims with thoracoabdominal wounds by pulmonology surgeons. It is necessary to control hemostasis during surgical interventions in the lung and mediastinal organs, as well as correctly and accurately perform invasive procedures.

The prognosis of hemothorax depends on how severe is the damage to the chest and nearby organs, as well as the volume of blood loss and the adequacy of emergency interventions. In addition, the effectiveness of treatment may depend on the nature of the damage (unilateral or bilateral hemorrhage). A more optimistic prognosis is determined with a small and medium degree of haptology. The curled form increases the risk of pleural empyema. The consequences of hemothorax, accompanied by prolonged or simultaneous bleeding, are most pessimistic, up to the lethal outcome of the patient.

If the treatment was provided in a timely and competent manner, then in the future the forecast is usually favorable. Patients are recommended during the rehabilitation period to start swimming, walking, performing special breathing exercises to prevent the formation of pleural adhesions, which can significantly affect the function of the diaphragm dome. It is necessary to understand that hemothorax is a very serious condition, and the recovery period can be quite long.