Introduction
Accumulation of blood within the chest, or hemothorax, is a relatively common problem, most often resulting from injury to intrathoracic structures or the chest wall. Hemothorax unrelated to trauma is considerably less common and can result from various causes. Prompt identification and treatment of traumatic hemothorax is an essential part of the care of the injured patient. In cases of hemothorax unrelated to trauma, a careful investigation for the underlying source must be performed while treatment is occurring.
History of the Procedure
Hemorrhage from or within the chest has been detailed in numerous medical writings dating back to ancient times. While lesser forms of trauma were commonly treated in the ancient physician's daily practice, major injuries, especially those to the chest, were difficult to treat and often lethal.
By the 18th century, some treatment for hemothorax was available; however, controversy raged about its form. A number of surgeons, including John Hunter in 1794, advocated the creation of an intercostal incision and drainage of the hemothorax. Those of the opposing viewpoint believed that closure of chest wounds without drainage and other conservative forms of management of bloody collections in the chest were proper treatment. While Hunter's method was effective in evacuating the hemothorax, the morbidity associated with the creation of an iatrogenic pneumothorax as a result of the procedure was significant. On the other hand, the risks associated with wound closure or conservative management included the possibility that empyema with sepsis would develop or that persistent trapped lung with permanent reduction of pulmonary function would result.
Observing the advantages and dangers of both forms of therapy, Guthrie, in the early 1800s, gave credence to both viewpoints. He did this by proposing the importance of early evacuation of blood through an existing chest wound and, at the same time, asserting that if bleeding from the chest persisted, the wound should be closed in the hope that existing intrathoracic pressure would halt the bleeding. If the desired effect was accomplished, he advised that the wound be reopened several days later for the evacuation of retained clotted blood or serous fluid.
By the 1870s, early hemothorax evacuation by trocar and cannula or by intercostal incision was considered standard practice. Not long after this, underwater seal drainage was described by a number of different physicians. This basic technique has remained the most common form of treatment for hemothorax and other pleural fluid collections to this day.1
Problem
Hemothorax refers to a collection of blood within the pleural cavity. Although some authors state that a hematocrit value of at least 50% is necessary to define a hemothorax (compared to a bloody pleural effusion), most do not agree on any specific distinction. Although the most common etiology of hemothorax is blunt or penetrating trauma, it can also result from a number of nontraumatic causes or can occur spontaneously.
Frequency
Quantifying the frequency of hemothorax in the general population is difficult. A very small hemothorax can be associated with a single rib fracture and may go undetected or require no treatment. Because most major hemothoraces are related to trauma, a rough estimate of their occurrence may be gleaned from trauma statistics.
Approximately 150,000 deaths occur from trauma each year. Approximately 3 times this number of individuals are permanently disabled because of trauma, and the majority of this combined group are victims of polytrauma. Chest injuries occur in approximately 60% of polytrauma cases; therefore, a rough estimate of the occurrence of hemothorax related to trauma in the United States approaches 300,000 cases per year.2
Etiology
By far, the most common cause of hemothorax is trauma. The various etiologies follow.
- Traumatic
- Blunt trauma
- Penetrating trauma (including iatrogenic)
- Nontraumatic or spontaneous
- Neoplasia (primary or metastatic)
- Blood dyscrasias, including complications of anticoagulation
- Pulmonary embolism with infarction
- Torn pleural adhesions in association with spontaneous pneumothorax
- Bullous emphysema
- Necrotizing infections
- Tuberculosis (Click here to complete a Medscape CME activity on screening for tuberculosis.)
- Pulmonary arteriovenous fistulae
- Hereditary hemorrhagic telangiectasia
- Nonpulmonary intrathoracic vascular pathology (eg, thoracic aortic aneurysm, aneurysm of the internal mammary artery)
- Intralobar and extralobar sequestration
- Abdominal pathology (eg, pancreatic pseudocyst, splenic artery aneurysm, hemoperitoneum)
- Catamenial
Pathophysiology
Bleeding into the pleural space can occur with virtually any disruption of the tissues of the chest wall and pleura or the intrathoracic structures.
The physiologic response to the development of a hemothorax is manifested in 2 major areas: hemodynamic and respiratory. The degree of hemodynamic response is determined by the amount and rapidity of blood loss.
Normal respiratory movement may be hampered by the space-occupying effect of a large accumulation of blood within the pleural space. In trauma cases, abnormalities of ventilation and oxygenation may result, especially if associated with injuries to the chest wall. In some cases of nontraumatic origin, especially those associated with pneumothorax and a limited amount of bleeding, respiratory symptoms may predominate.
Systemic physiologic response - Hemodynamic
Hemodynamic changes vary depending on the amount of bleeding and the rapidity of blood loss. Blood loss of up to 750 mL in a 70-kg man should cause no significant hemodynamic change. Loss of 750-1500 mL in the same individual will cause the early symptoms of shock, ie, tachycardia, tachypnea, and a decrease in pulse pressure.
Significant signs of shock with signs of poor perfusion occur with loss of blood volume of 30% or more (1500-2000 mL). Because the pleural cavity of a 70-kg man can hold 4 or more liters of blood, exsanguinating hemorrhage can occur without external evidence of blood loss.
Systemic physiologic response - Respiratory
Blood occupying the pleural cavity takes up space that the lung would fill in normal respiratory excursion. A large enough collection causes the patient to complain of dyspnea and may produce the clinical finding of tachypnea. The volume of blood required to produce these symptoms in a given individual varies depending on a number of factors, including organs injured, severity of injury, and underlying pulmonary and cardiac reserve.
Dyspnea is a common symptom in cases in which hemothorax develops in an insidious manner, such as those secondary to metastatic disease. Blood loss in such cases is not acute as to produce a visible hemodynamic response, and dyspnea is often the predominant complaint.
Physiologic resolution of the hemothorax
Blood that enters the pleural cavity is exposed to the motion of the diaphragm, lungs, and other intrathoracic structures. This results in some degree of defibrination of the blood so that incomplete clotting occurs. Within several hours of cessation of bleeding, lysis of existing clots by pleural enzymes begins.
Lysis of red blood cells results in a marked increase in the protein concentration of the pleural fluid and an increase in the osmotic pressure within the pleural cavity. This elevated intrapleural osmotic pressure produces an osmotic gradient between the pleural space and the surrounding tissues that favors transudation of fluid into the pleural space. In this way, a small and asymptomatic hemothorax can progress into a large and symptomatic bloody pleural effusion.
Late physiologic sequelae of unresolved hemothorax
Two pathologic states are associated with the later stages of hemothorax. These include empyema and fibrothorax.
Empyema results from bacterial contamination of the retained hemothorax. If undetected or improperly treated, this can lead to bacteremia and septic shock.
Fibrothorax results when fibrin deposition develops in an organized hemothorax and coats both the parietal and visceral pleural surfaces, trapping the lung. The lung is fixed in position by this adhesive process and is unable to fully expand. Persistent atelectasis of portions of the lung and reduced pulmonary function result from this process.
Presentation
A number of the clinical findings associated with traumatic hemothorax vary from those that occur in the absence of trauma. These entities are discussed separately.
Traumatic hemothorax
Symptoms and physical findings associated with hemothorax in trauma vary widely depending on the amount and rapidity of bleeding, the existence and severity of underlying pulmonary disease, the nature and degree of associated injuries, and the mechanism of injury.
- Blunt trauma - Hemothorax with blunt chest wall injuries
- Hemothorax is rarely a solitary finding in blunt trauma. Associated chest wall or pulmonary injuries are nearly always present.
- Simple bony injuries consisting of one or multiple rib fractures are the most common blunt chest injuries. A small hemothorax may be associated with even single rib fractures but often remains unnoticed during the physical examination and even after chest radiography. Such small collections rarely need treatment.
- Complex chest wall injuries are those in which either 4 or more sequential single rib fractures are present or a flail chest exists. These types of injuries are associated with a significant degree of chest wall damage and often produce large collections of blood within the pleural cavity and substantial respiratory impairment. Pulmonary contusion and pneumothorax are commonly associated injuries. Injuries resulting in laceration of intercostal or internal mammary arteries may produce a hemothorax of significant size and significant hemodynamic compromise. These vessels are the most common source of persistent bleeding from the chest after trauma.
- Delayed hemothorax can occur at some interval after blunt chest trauma. In such cases, the initial evaluation, including chest radiography, reveals findings of rib fractures without any accompanying intrathoracic pathology. However, hours to days later, a hemothorax is seen. The mechanism is believed to be either rupture of a trauma-associated chest wall hematoma into the pleural space or displacement of rib fracture edges with eventual disruption of intercostal vessels during respiratory movement or coughing.
- Blunt intrathoracic injuries
- Large hemothoraces are usually related to injury of vascular structures. Disruption or laceration of major arterial or venous structures within the chest may result in massive or exsanguinating hemorrhage.
- Hemodynamic manifestations associated with massive hemothorax are those of hemorrhagic shock. Symptoms can range from mild to profound, depending on the amount and rate of bleeding into the chest cavity and the nature and severity of associated injuries.
- Because a large collection of blood will compress the ipsilateral lung, related respiratory manifestations include tachypnea and, in some cases, hypoxemia.
- A variety of physical findings such as bruising, pain, instability or crepitus upon palpation over fractured ribs, chest wall deformity, or paradoxical chest wall movement may lead to the possibility of coexisting hemothorax in cases of blunt chest wall injury. Dullness to percussion over a portion of the affected hemithorax is often noted and is more commonly found over the more dependent areas of the thorax if the patient is upright. Decreased or absent breath sounds upon auscultation are noted over the area of hemothorax.
- Penetrating trauma
- Hemothorax from penetrating injury is most commonly caused by direct laceration of a blood vessel. While arteries of the chest wall are most commonly the source of hemothorax in penetrating injury, intrathoracic structures, including the heart, should also be considered.
- Pulmonary parenchymal injury is very common in cases of penetrating injury and usually results in a combination of hemothorax and pneumothorax. Bleeding in these cases is usually self-limited.3
Clinical caveats in traumatic hemothorax
Positive physical findings noted by percussion and auscultation are best appreciated in the upright patient and, even then, may be subtle. As much as 400-500 mL of blood may obliterate only the space comprising the costophrenic angle.
Many trauma victims are initially examined in the supine position. In such cases, a collection of blood within the pleural space will not occupy the diaphragmatic surface, but will be distributed along the entire posterior aspect of the affected pleural space. Physical examination techniques such as percussion and auscultation may produce equivocal findings even though a substantial collection of blood is present.
A hemothorax found in association with a diaphragmatic injury in either penetrating or blunt trauma may actually have its origin from an intra-abdominal source. Blood from injured abdominal organs may traverse a diaphragmatic tear and enter the thoracic cavity. In cases of hemothorax with diaphragmatic injury, the clinician should strongly consider the possibility of intra-abdominal injury.4
Nontraumatic hemothorax
Symptoms and physical findings are variable, depending on the underlying pathology.
- Hemothorax secondary to acute hemorrhage from structures within the chest can produce profound hemodynamic changes and symptoms of shock. Massive hemothorax can result from vascular structures such as a ruptured or leaking thoracic aortic aneurysm or from pulmonary sources such as lobar sequestration or arteriovenous malformation. Disruption of a vascular pleural adhesion unrelated to trauma can produce a significant hemothorax with an associated spontaneous pneumothorax.
- Occult hemorrhage is most commonly related to metastatic disease or complications of anticoagulation. In these situations, bleeding into the pleural cavity occurs slowly, resulting in subtle or absent changes in hemodynamics. When the effusion is large enough to produce symptoms, dyspnea is usually the most prominent complaint. Signs of anemia may also be present. Physical examination reveals findings similar to those for any pleural effusion, with dullness to percussion and decreased breath sounds noted over the area of the effusion.
- Hemothorax in conjunction with pulmonary infarction is usually preceded by clinical findings associated with pulmonary embolism.
- Catamenial hemothorax is an unusual problem related to thoracic endometriosis. Hemorrhage into the thorax is periodic, coinciding with the patient's menstrual cycle.
Indications
If a hemothorax is equal to or greater than the amount required to obscure the costophrenic sulcus or is found in association with a pneumothorax based on chest radiograph findings, it should be drained by tube thoracostomy. In cases of hemopneumothorax, 2 chest tubes may be preferred, with the tube draining the pneumothorax placed in a more superior and anterior position.
Surgical exploration in cases of traumatic hemothorax should be performed in the following circumstances:
- Greater than 1000 mL of blood is evacuated immediately after tube thoracostomy. This is considered a massive hemothorax.
- Bleeding from the chest continues, defined as 150-200 mL/h for 2-4 hours.
- Persistent blood transfusion is required to maintain hemodynamic stability.
The late sequelae of hemothorax, including residual clot, infected collections, and trapped lung, require additional treatment and, most often, surgical intervention.
Retained clot (defined as an undrained collection of 500 mL or more as estimated by CT scan findings or opacification of one third or more of the chest on chest radiographs) is a well-known sequela after initial tube thoracostomy for hemothorax and should be evacuated early in the patient's hospital course, if the clinical condition permits. Early intervention in the case of a retained clot can be performed with thoracoscopy, provided the operation is planned within 1 week of the bleeding episode.
Empyema usually develops from superimposed infection in a retained collection of blood. It requires surgical drainage and, possibly, decortication.
Fibrothorax is a late uncommon complication that can result from retained hemothorax. Thoracotomy and decortication are required for treatment.
Relevant Anatomy
Extrapleural
In cases of trauma, disruption of the chest wall tissues with violation of the pleural membrane can cause bleeding into the pleural cavity. The most likely sources of significant or persistent bleeding from chest wall injuries are the intercostal and internal mammary arteries.
In nontraumatic cases, rare disease processes within the chest wall (eg, bony exostoses) can be responsible.
Intrapleural
Blunt or penetrating injury involving virtually any intrathoracic structure can result in hemothorax. Massive hemothorax or exsanguinating hemorrhage may result from injury to major arterial or venous structures contained within the thorax or from the heart itself. These include the aorta and its brachiocephalic branches, the main or branch pulmonary arteries, the superior vena cava and the brachiocephalic veins, the inferior vena cava, the azygous vein, and the major pulmonary veins.
Injury to the heart can produce a hemothorax if a communication exists between the pericardium and the pleural space.
Injury to the pulmonary parenchyma may cause hemothorax, but it is usually self-limited because pulmonary vascular pressure is normally low. Pulmonary parenchymal injury is usually associated with pneumothorax and results in limited hemorrhage.
Hemothorax resulting from metastatic malignant disease is usually from tumor implants that seed the pleural surfaces of the thorax.
Diseases of the thoracic aorta and its major branches, such as dissection or aneurysm formation, account for a large percentage of specific vascular abnormalities that can cause hemothorax. Aneurysms of other intrathoracic arteries such as the internal mammary artery have been described and are possible causes of hemothorax if rupture occurs.
A variety of unusual congenital pulmonary abnormalities, including intra- and extralobar sequestration, hereditary telangiectasia, and congenital arteriovenous malformations, can cause hemothorax.
Hemothorax can result from pathology originating within the abdomen if bleeding from the abnormality is able to traverse the diaphragm through one of the normal hiatal openings or a congenital or acquired opening.
Contraindications
Needle aspiration of a hemothorax is generally not indicated for definitive treatment.
In some cases of nontraumatic hemothorax, especially those that occur from metastatic pleural implants, patients may present with the finding of a new pleural effusion of unknown etiology and hemothorax may not be identified until the initial diagnostic aspiration is performed. Although the diagnostic evaluation in such cases may be performed using needle aspiration, complete evacuation of these collections often requires treatment with tube thoracostomy, similar to hemothoraces resulting from other causes.
Although not contraindicated, drainage of hemothorax or any pleural effusion in an individual with a coagulopathy should be performed with great care. This group includes patients receiving anticoagulation therapy and those with significant liver disease or inherited coagulation factor deficiencies. Normalization of coagulation function by cessation of anticoagulants and/or correction of factor deficiencies using appropriate blood products, if necessary, should be initiated prior to a drainage procedure, if possible.
Needle aspiration should not be performed if clotting deficiencies are present. Rather, tube thoracostomy should be used, with the ability to visualize and control any chest wall bleeding that is encountered. If necessary, in individuals requiring long-term anticoagulant therapy, this medication can be resumed 8-12 hours after the thoracostomy has been completed.
Tube thoracostomy drainage of a hemothorax is relatively contraindicated when significant pleural adhesions are known to be present. Incomplete drainage or inability to effectively access the area is likely. Also, blunt division of pleural adhesions may cause additional bleeding and result in lung laceration. If evacuation of such collections is mandated clinically, thoracotomy with division of adhesions under direct vision is the safer approach.
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Further Reading
Keywords
haematothorax, haemothorax, hematothorax, chest wall injury, intrathoracic injury, trauma, chest wall hemorrhage, intrathoracic hemorrhage, penetrating trauma, blunt trauma, polytrauma, primary neoplasia, metastatic neoplasia, blood dyscrasias, anticoagulation complications, pulmonary embolism, PE, torn pleural adhesion, bullous emphysema, necrotizing infections, tuberculosis, TB, pulmonary arteriovenous fistula, hereditary hemorrhagic telangiectasia, thoracic aortic aneurysm, internal mammary artery aneurysm, intralobar sequestration, extralobar sequestration, pancreatic pseudocyst, splenic artery aneurysm, hemoperitoneum, catamenial hemothorax
