Hemothorax
Encyclopedia
A hemothorax is a condition that results from blood accumulating in the pleural cavity
.
, resulting in a rupture of the serous membrane
either lining the thorax or covering the lungs. This rupture allows blood to spill into the pleural space, equalizing the pressures between it and the lungs. Blood loss may be massive in people with these conditions, as each side of the thorax can hold 30–40% of a person's blood volume. Even minor injury to the chest wall can lead to significant hemothorax.
and the trachea
, effectively limiting the amount that the heart's ventricles
are able to fill. The condition can cause the trachea to deviate, or move, toward the unaffected side.
already in the thoracic cavity
. Blood in the cavity can be removed by inserting a drain (chest tube
) in a procedure called a tube thoracostomy. Usually the lung will expand and the bleeding will stop after a chest tube is inserted. The blood in the chest can thicken as the clotting cascade is activated when the blood leaves the blood vessels and is activated by the pleural surface, injured lung or chest wall, or contact with the chest tube. As the blood thickens, it can clot in the pleural space (leading to a retained hemothorax) or within the chest tube, leading to chest tube clogging or occlusion. Chest tube clogging or occlusion can lead to worse outcomes as it prevents adequate drainage of the pleural space, contributing to the problem of retained hemothorax. In this case, patients can be hypoxic, short of breath, or in some cases, the retained hemothorax can become infected (empyema
). Therefore adequately functioning chest tubes are essential in the setting of a hemothorax treated with a chest tube. To attempt to minimize the potential for clogging, the surgeons will often place more than one tube, or large diameter tubes. Maintaining an adequately functioning chest tube is an active process, usually for the nurses, that often requires tapping the tubes, milking the tubes, or stripping the tubes to minimize potential for clogging in the tube in the setting of a hemothorax. When these efforts fail a new chest tube must be placed, or the patient must be taken to the operating room by a surgeon to open the chest and remove the blood clot, and re insert adequately functioning chest tubes.
Thrombolytic agents have been used to break up clot in tubes or when the clot becomes organized in the pleural space, however this is risky as it can lead to increased bleeding and the need for reoperation. Therefore, ideally, the tubes maintain their function so that the blood cannot clot in the chest or the tube.
In some cases bleeding continues and surgery is necessary to stop the source of bleeding. For example, if the cause is rupture of the aorta
in high energy trauma, the intervention by a thoracic surgeon is mandatory.
Pleural cavity
In human anatomy, the pleural cavity is the potential space between the two pleura of the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally...
.
Cause and presentation
Its cause is usually traumatic, from a blunt or penetrating injury to the thoraxChest
The chest is a part of the anatomy of humans and various other animals. It is sometimes referred to as the thorax or the bosom.-Chest anatomy - Humans and other hominids:...
, resulting in a rupture of the serous membrane
Serous membrane
In anatomy, serous membrane is a smooth membrane consisting of a thin layer of cells which secrete serous fluid. Serous membranes line and enclose several body cavities, known as serous cavities, where they secrete a lubricating fluid which reduces friction from muscle movement...
either lining the thorax or covering the lungs. This rupture allows blood to spill into the pleural space, equalizing the pressures between it and the lungs. Blood loss may be massive in people with these conditions, as each side of the thorax can hold 30–40% of a person's blood volume. Even minor injury to the chest wall can lead to significant hemothorax.
Prognosis
If left untreated, the condition can progress to a point where the blood accumulation begins to put pressure on the mediastinumMediastinum
The mediastinum is a non-delineated group of structures in the thorax, surrounded by loose connective tissue. It is the central compartment of the thoracic cavity...
and the trachea
Vertebrate trachea
In tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
, effectively limiting the amount that the heart's ventricles
Ventricle (heart)
In the heart, a ventricle is one of two large chambers that collect and expel blood received from an atrium towards the peripheral beds within the body and lungs. The Atria primes the Pump...
are able to fill. The condition can cause the trachea to deviate, or move, toward the unaffected side.
Signs and symptoms
- TachypneaTachypneaTachypnea means rapid breathing. Any rate between 12-20 breaths per minute is normal. Tachypnea is a respiration rate greater than 20 breaths per minute. - Distinction from other breathing terms :...
- DyspneaDyspneaDyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...
- CyanosisCyanosisCyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is...
- Decreased or absent breath sounds on affected side
- TrachealVertebrate tracheaIn tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
deviation to unaffected side - Dull resonance on percussion
- Unequal chest rise
- TachycardiaTachycardiaTachycardia comes from the Greek words tachys and kardia . Tachycardia typically refers to a heart rate that exceeds the normal range for a resting heart rate...
- HypotensionHypotensionIn physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
- Pale, cool, clammy skin
- Possibly subcutaneous emphysemaSubcutaneous emphysemaSubcutaneous emphysema, sometimes abbreviated SCE or SE and also called tissue emphysema, or Sub Q air, occurs when gas or air is present in the subcutaneous layer of the skin. Subcutaneous refers to the tissue beneath the cutis of the skin, and emphysema refers to trapped air...
- Narrowing pulse pressurePulse pressurePulse Pressure is most easily defined as being the amount of pressure required to create the feeling of a pulse. Measured in millimeters of mercury , the pressure difference between the systolic and diastolic pressures give you the amount of pressure change to create the pulse, which is the pulse...
Management
A hemothorax is managed by removing the source of bleeding and by draining the bloodBlood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
already in the thoracic cavity
Thoracic cavity
The thoracic cavity is the chamber of the human body that is protected by the thoracic wall ....
. Blood in the cavity can be removed by inserting a drain (chest tube
Chest tube
A chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air or fluid , or pus from the intrathoracic space...
) in a procedure called a tube thoracostomy. Usually the lung will expand and the bleeding will stop after a chest tube is inserted. The blood in the chest can thicken as the clotting cascade is activated when the blood leaves the blood vessels and is activated by the pleural surface, injured lung or chest wall, or contact with the chest tube. As the blood thickens, it can clot in the pleural space (leading to a retained hemothorax) or within the chest tube, leading to chest tube clogging or occlusion. Chest tube clogging or occlusion can lead to worse outcomes as it prevents adequate drainage of the pleural space, contributing to the problem of retained hemothorax. In this case, patients can be hypoxic, short of breath, or in some cases, the retained hemothorax can become infected (empyema
Empyema
Pleural empyema is an accumulation of pus in the pleural cavity. Most pleural empyemas arise from an infection within the lung , often associated with parapneumonic effusions. There are three stages: exudative, fibrinopurulent and organizing. In the exudative stage, the pus accumulates...
). Therefore adequately functioning chest tubes are essential in the setting of a hemothorax treated with a chest tube. To attempt to minimize the potential for clogging, the surgeons will often place more than one tube, or large diameter tubes. Maintaining an adequately functioning chest tube is an active process, usually for the nurses, that often requires tapping the tubes, milking the tubes, or stripping the tubes to minimize potential for clogging in the tube in the setting of a hemothorax. When these efforts fail a new chest tube must be placed, or the patient must be taken to the operating room by a surgeon to open the chest and remove the blood clot, and re insert adequately functioning chest tubes.
Thrombolytic agents have been used to break up clot in tubes or when the clot becomes organized in the pleural space, however this is risky as it can lead to increased bleeding and the need for reoperation. Therefore, ideally, the tubes maintain their function so that the blood cannot clot in the chest or the tube.
In some cases bleeding continues and surgery is necessary to stop the source of bleeding. For example, if the cause is rupture of the aorta
Aorta
The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries...
in high energy trauma, the intervention by a thoracic surgeon is mandatory.
See also
- Cardiac tamponadeCardiac tamponadeCardiac tamponade, also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium ....
- HemopneumothoraxHemopneumothoraxHemopneumothorax, or haemopneumothorax, is a medical term describing the combination of two conditions: pneumothorax, or air in the chest cavity, and hemothorax , or blood in the chest cavity....
- Pleural effusionPleural effusionPleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.-Pathophysiology:...
- PneumothoraxPneumothoraxPneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
- Tension pneumothorax
- Pulmonary contusionPulmonary contusionA pulmonary contusion is a contusion of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels...