Definition

• Hemothorax: pleural Hct >50% of serum Hct

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Etiology

• Chest Trauma (Penetrating/Non-Penetrating)
• Coagulopathy (see Coagulopathy, [[Coagulopathy]])
  • Anticoagulation: especially for pulmonary embolism
    • Usually occurs 4-7 days after starting anticoagulation therapy, but may occur months later
  • Hemophilia
  • Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]])
• Iatrogenic Hemothorax
  • Central Venous Catheter Placement (see Central Venous Catheter, [[Central Venous Catheter]])
  • Esophageal Variceal Sclerotherapy (see Esophagogastroduodenoscopy, [[Esophagogastroduodenoscopy]])
  • Pleural Biopsy
  • Thoracentesis (see Thoracentesis, [[Thoracentesis]])
  • Trans-Bronchial Biopsy
  • Trans-Lumbar Aortogram
• Idiopathic Hemothorax
• Intrathoracic Extramedullary Hematopoeisis (see Extramedullary Hematopoiesis, [[Extramedullary Hematopoiesis]])
• Pleural Metastases (see Pleural Metastases, [[Pleural Metastases]])
• Pulmonary Endometrioma (see xxxx, [[xxxx]]): catamenial pneumothorax/hemothorax may occur
• Pulmonary Sequestration (see Pulmonary Sequestration, [[Pulmonary Sequestration]])
• Rupture of Thoracic Vessel
  • Aortic Coarctation (see Aortic Coarctation, [[Aortic Coarctation]])
  • Patent Ductus Arteriosus (see Patent Ductus Arteriosus, [[Patent Ductus Arteriosus]])
  • Ruptured Thoracic Aortic Aneurysm (see Thoracic Aortic Aneurysm, [[Thoracic Aortic Aneurysm]])
  • Ruptured Pulmonary Artery Aneurysm (see Pulmonary Artery Aneurysm, [[Pulmonary Artery Aneurysm]])
• Ruptured Splenic Artery Aneurysm: with leakage of blood across the diaphragm or rupture directly into the pleural space
• Spontaneous Pneumothorax (see Pneumothorax, [[Pneumothorax]]
• Varicella Pneumonia (see Varicella-Zoster Virus, [[Varicella-Zoster Virus]])

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Physiology

• Presence of blood in pleural space due to injury to chest wall/ diaphragm/ lung/ blood vessels/ mediastinum

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Diagnosis

• Pleural Fluid
  • Hct: hemothorax is defined as pleural fluid Hct >50% of periperal blood Hct
  • RBC/WBC ratio: approaches that of peripheral blood
  • Protein ratio: approaches that of serum
  • LDH ratio: approaches that of serum
  • Eosinophilia: pleural fluid eosinophilia typically appears later, during second week
• CXR/Chest CT patterns
  • Pleural effusion
  • Pneumothorax (>50% of traumatic hemothoraces have associated pneumothorax)

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Clinical

• Dyspnea
• Cough
• Signs of pleural effusion
• Complications
  • Retention of clotted blood in pleural space
  • Fibrothorax (loculation occurs early but fibrothorax occurs in <1% of cases): predisposed by presence of associated pneumothorax/ empyema
  • Empyema (occurs in 1-4% of cases): predisposed by shock/ gross contamintaion of pleural space/ associated abdominal injury/ prolonged pleural drainage/ prevented by prophylactic antibiotics
  • Pleural effusion (occurs after chest tube removal in >10% of cases): most resolve spontaneously, but should do thoracentesis to rule out infection
  • Rounded Atelectasis (see xxxx, [[]])

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Treatment

• Correction of bleeding diathesis (if present)
• Chest tube: place immediately
  • Rationale: complete evacuation of blood/ tamponades bleeding, if pleural lacerations are present/ decreases risk of future empyema and fibrothorax/ blood may be autotransfused
  • Large bore tube placed high (fourth-fifth intercostal space) in midaxillary line to avoid diaphragm (if it is injured)
• Thoracotomy: indicated in 20% of cases (due to suspected cardiac tamponade/ vascular injury/ pleural contamination/ debridement of devitalized tissue/ sucking chest wounds/ major bronchial air leaks/ continued pleural hemorrhage (>100-200 mL/hr)
  • Also indicated for retention of clots in pleural space of >30% of hemithorax
• Thoracoscopy: may be used in some cases

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References

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