HEMOTHORAX
Hemothorax is defined as the presence of blood in the pleural space.
• Source of blood:
1. Chest wall
2. Lung parenchyma
3. Heart
4. Great vessels
• Hemothorax is usually a consequence of blunt or penetrating trauma,
complication of a disease, iatrogenicaly induced, or spontaneously developed.
Causes
1. Traumatic causes
• Penetrating injuries of heart, lungs, great vessels, chest wall
2. Iatrogenic causes
• Central venous catheter
• Thoracostomy tube placement
3. Non-traumatic/spontaneous causes
• Neoplasia (primary or metastatic)
• Complications of anticoagulation
• Pulmonary embolism with infarction
• Bullous emphysema
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Necrotizing infections
Tuberculosis
Pulmonary arteriovenous fistulae
Thoracic aortic aneurysm
Splenic artery aneurysm
Pancreatic pseudocysts
Hemoperitoneum
Vitamin K deficiency
Congenital cystic adenomatoid malformations
Signs and symptoms
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Tachypnoea
Tachycardia
If substantial systemic blood loss has occurred
Hypotension
Shallow breathing
Dull percussion
Diminished ipsilateral breath sound
Pain and feeling of heaviness in chest
Anxiety
Dyspnoea
Skin turning pale
High fever over 38°C
Pathophysiology
➢ There are 2 layers of pleura
• Visceral pleura- inside
• Parietal pleura- outside
➢ These layers of pleura adhere to each other to keep the lung from collapsing,
even with the expiration of the air from the lung
➢ If blood enters in to the pleural cavity, it causes lung collapse due to elastic
recoil.
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➢ Physiologic response to the development of hemothorax is manifested in 2
major areas
• Hemodynamic response
• Respiratory response
➢ Hemodynamic response
• Hemodynamic changes vary, depending on the amount of bleeding and
the rapidity of blood loss
• Blood loss up to 750ml in a 70kg Causes no significant hemodynamic
changes.
• Blood loss of 750 – 1500ml in the same individual can show early
symptoms of shock(tachycardia, tachypnea and decreased pulse
pressure)
• Blood loss of 1500-2000ml gives significant signs of shock.
• Pleural cavity of a 70kg man can hold 4L of blood without external
evidence of blood loss.
➢ Respiratory response
• Large accumulation of blood within the pleural space may hamper
normal respiratory movement.
• In trauma cases, abnormalities of ventilation and oxygenation may be
evident.
• Accumulation of this blood causes patient to experience dyspnoea,
tachypnea
Diagnosis
1. CT- Scan
• Is checked for structures around your heart and lungs for any
abnormalities
2. Chest X-ray
• Shifting of Mediastinum on the opposite side of the injury
• Broken bones in case of trauma
Differential diagnosis
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Emergent management of pleural effusion
Inteathoracic malignancy
Metastatic malignancy
Pediatric empyema
Treatment
1. Medical management
➢ Tube thoracostomy (Chest tube drainage)
• On insertion, thoracotomy tube is Directed towards the
costophrenic angle.
• For maximum drainage, thoracotomy tube placement Hemothorax
should ideally be in the sixth or seventh intercostal space at the
posterior axillary line.
2. Surgical management
➢ Video assisted thoracoscopic surgery (VATS)
• It is an alternative treatment that permits direct removal of clot and
precise placement of chest tubes
• Post operative complications are less comparative of thoracostomy
➢ Thoracostomy
• It is the procedure of choice for surgical exploration of the chest
when massive Hemothorax or persistent bleeding is present.
• At the time of surgical exploration, the source of bleeding is
controlled and the Hemothorax is evacuated.
3. Physiotherapy management
• The patient’s clinical picture should lead the physiotherapist in deciding
what treatment is suitable.
• Help to improve ventilation, oxygenation and to re-inflate atelectatic lung
areas. This could be done through deep breathing exercise techniques.
• Help to improve the patient's exercise tolerance and mobility. This could
be done by assisting with mobilisation or general strengthening exercises.
• Help to maintain airway clearance. This could be done by showing the
patient assisted coughing techniques to help clear any secretions.
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