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Updated: Jul 1 2024

Massive Hemothorax

  • Snapshot
    • A 19-year-old male is brought to the emergency department following a gunshot wound to the chest. According to the first responders, the man was found unresponsive and was quickly intubated in the field. A physical examination demonstrates decreased lung sounds on the right field and a thoracostomy is quickly performed. The chest tube immediately drained 1600 mL of reddish fluid.
  • Introduction
    • Clinical definition
      • rapid accumulation of > 1000mL of blood within the pleural cavity
      • mostly commonly associated with traumatic injury with involvement of the great or hilar vessels
      • can also occur spontaneously (e.g., malignancy)
  • Epidemiology
    • Demographics
      • motor vehicle collisions (MVCs) represent the most common cause of major thoracic injury
      • about 300,000 cases in the U.S. every year
    • Risk factors
      • penetrating chest trauma (e.g., stab or bullet wounds)
      • motor vehicle accidents
      • malignancy
      • blood clotting disorder
    • Pathogenesis
      • trauma to the thoracic cavity leads to bleeding and subsequent blood pooling in the pleural cavity
        • interferes with normal movement of the lungs by preventing normal expansion of the lungs
      • acute systemic blood loss can lead to compensatory measures (e.g., tachycardia and peripheral vasoconstriction)
    • Associated conditions
      • rib fractures
      • pulmonary contusion
      • pericardial tamponade
      • tracheobronchial injury
      • esophageal injury
      • aortic injury
      • pneumothorax
  • Presentation
    • Symptoms
      • dyspnea
      • pleuritic chest pain
      • lightheadedness
    • Physical exam
      • vital sign abnormalities (e.g., hypotension and tachycardia)
      • diminished or absent breath sounds
      • dull lung sounds with percussion
      • collapsed neck veins
      • cyanosis (if large blood loss)
  • Differential
    • Tension pneumothorax
      • distinguishing factor
        • clinical features such as hyperresonnace
        • characteristic imaging findings
    • Flail chest
      • distinguishing factor
        • will see paradoxical movement of the chest wall
  • Treatment
    • Management approach
      • initial management consists of stabilization (e.g., oxygen) and fluid resuscitation with close monitoring for early signs of respiratory compromise
      • operative management is dependent on the extent of bleeding
    • First-line
      • small hemothorax
        • stabilization and expectant management
      • moderate to large hemothorax
        • drainage of blood via large-bore thoracostomy 
        • fluid resuscitation
      • if > 1500 mL of blood or > 200 mL/hour, hemodynamic instability, or need for repeated blood transfusions
        • emergency thoracotomy or video-associated thoracoscopic surgery (VATS)
    • Second-line
      • thoracotomy/VATS
        • if continued bleeding or retained blood clots
  • Complications
    • Empyema
      • more likely to occur if there is retained blood within the pleural cavity
    • Fibrothorax
      • formation of scar tissue secondary to pleural irritation from retained blood
    • Atelectasis
    • Pneumonia
    • Pneumothorax
    • Wound infection
    • Hemorrhagic shock and death
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