Haemothorax

DEFINITION
Accumulation of blood in the chest cavity as a result of trauma, impairing lung function.
See also massive haemothorax (>1500ml)
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EPIDEMIOLOGY
Chest trauma victims
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AETIOLOGY
Trauma.
- primarily lung laceration or intercostal vessel / mammary artery laceration.
- t-spine injury may be associated
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BIOLOGICAL BEHAVIOUR

Pathophysiology
Blood loss is complicated by hypoxia.

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MANIFESTATIONS

Symptoms

Chest trauma
Impaired ventilation

Signs
Observe
Neck veins may be flat due to severe hypovolaemia
- though beware: may be distended if also a tension pneumothorax, or sometimes from the haemothorax itself shifting the mediastinum.
Percuss
Dull
Auscultate
Decreased BS.
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INVESTIGATIONS

XR may show unilateral opacification
- general hazing if supine; else evidence of dependent fluid.
CT
USS
- sensitive in the right hands.
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MANAGEMENT

Tend to ABCDEs first as usual

Usually bleeding is self-limiting and does not require operative intervention.
Any haemothorax large enough to be seen on a CXR should be chest drained.
- removes blood
- reduces risk of 'clotted haemothorax' / fibrothorax
- monitors ongoing blood loss
- allows better assessment of possible diaphragmatic injury.

If >1500ml evacuated, early thoracotomy.
OR >200ml/hr for 4 hrs.

Decision is based on physiologic status as well
- e.g. persistent blood transfusion requirement is an indication for thoracotomy.
- be aware of clotting of the thoracostomy tube.
- penetrating wounds medial to the nipple line and posterior wounds medial to the scapula should alert to the need of thoracotomy because of damage to the great vessels, hilar structures and heart and associated risk of cardiac tamponade.

Fibrothorax
Any haemothorax evident on CXR should be drained
Failure to evacuate leads to fibrothorax
Chronically diminished pulmonary function, pain, dyspnoea.
Aggressive therapy required for retained haemothorax.
CT scan, if >1/3 of pleural space, evacuate by thoracoscopic surgery.
- because chest tubes placed >24h after surgery fail to evacuate clot in 50%.

Thoracotomy
Best achieved in lateral decubitus position through posterolateral approach.
Anterolateral thoracotomy if haemodynamically unstable.
5th ICS = best exposure.

Sources of bleeding include:
- internal mammary
- intercostal vessels
- lung parenchyma
- great vessels

Lung parenchyma
Tractotomy or wedge resections to expose, seal and resect source of haemorrhage from parenchyma
Formal lobectomy or pneumectomy for severe parenchymal injury
Vascular control of hilum achieved by incising inferior pulmonary ligament, clamping hilar vessels with hand or vascular clamp.
Twisting hilum 180 degrees can be helpful.
- can then assess source of bleeding and manage.

Damage control chest surgery?
Rarely done; in cold coagulopathic acidotic patients, chest packing can be employed to temporarily gain physiological ground.


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REFERENCES
ATLS