Hemotoraks

12. 12. HEMOTHORAXHEMOTHORAX

PLEURAL DISEASES SERIES 08PLEURAL DISEASES SERIES 08

BY WIDIRAHARDJOBY WIDIRAHARDJO

12. HEMOTHORAX12. HEMOTHORAX

Hemothorax is the presence of Hemothorax is the presence of a significant amount of blood a significant amount of blood in the pleural space.in the pleural space.

Most hemothoraces result Most hemothoraces result from penetrating or from penetrating or nonpenetrating chest trauma.nonpenetrating chest trauma.


On rare occasions: from On rare occasions: from iatrogenic manipulation such as iatrogenic manipulation such as the placement of central venous the placement of central venous catheters percutaneously by the catheters percutaneously by the subclavian or internal jugular subclavian or internal jugular route or from translumbar route or from translumbar aortography, pulmonary aortography, pulmonary embolism or rupture of an aortic embolism or rupture of an aortic aneurysm and catamenial aneurysm and catamenial hemothoraxhemothorax


Blood entering the pleural Blood entering the pleural space coagulates rapidly, but space coagulates rapidly, but result of physical agitation result of physical agitation produced by movement of the produced by movement of the heart and the lungs, the clot heart and the lungs, the clot may be defibrinated.may be defibrinated.

Loculation occurs early in the Loculation occurs early in the course of hemothorax, as with course of hemothorax, as with empyema.empyema.


A hemothorax should be A hemothorax should be considered only when the pleural considered only when the pleural fluid hematocrit is equal to or fluid hematocrit is equal to or greater than 50% of the greater than 50% of the peripheral blood hematocrit.peripheral blood hematocrit.

The treatment of choice for The treatment of choice for patients with traumatic patients with traumatic hemothorax is the immediate hemothorax is the immediate insertion, except if only a very insertion, except if only a very small hemothorax, of a large-small hemothorax, of a large-bore chest tubes (size 36 to 40 bore chest tubes (size 36 to 40 F)F) chest tube.chest tube.


The advantages of the immediate The advantages of the immediate institution of tube thoracostomy are: institution of tube thoracostomy are:

a. Allows more complete a. Allows more complete evacuationevacuation

of the blood from the pleuralof the blood from the pleural

space; space;

b. Stops the bleeding if the b. Stops the bleeding if the bleedingbleeding

is from pleural lacerations; is from pleural lacerations;

c. Allows one to quantitate easily c. Allows one to quantitate easily thethe

amount of continued bleeding; amount of continued bleeding;


d. May decrease the incidence ofd. May decrease the incidence of

subsequent empyema because subsequent empyema because blood isblood is

a good culture medium;a good culture medium;

e. The blood drained from the e. The blood drained from the pleuralpleural

space may be autotransfused; space may be autotransfused;

f. The rapid evacuation of pleural f. The rapid evacuation of pleural bloodblood

decreases the incidence ofdecreases the incidence of

subsequent fibrothorax.subsequent fibrothorax.


Chest tubes were checked Chest tubes were checked every 6 hours and were every 6 hours and were removed when there was no air removed when there was no air leak and there was less than 50 leak and there was less than 50 mL drainage in the previous 6 mL drainage in the previous 6 hours.hours.

Vascular injury is suggested if Vascular injury is suggested if the initial chest tube output is the initial chest tube output is more than 1,500 mL.more than 1,500 mL.


Immediate thoracotomy or Immediate thoracotomy or thoracoscopy is indicated for thoracoscopy is indicated for suspected cardiac tamponade, suspected cardiac tamponade, vascular injury, pleural vascular injury, pleural contamination, debridement of contamination, debridement of devitalized tissue, sucking chest devitalized tissue, sucking chest wounds, or major bronchial air wounds, or major bronchial air leaks.leaks.


Continued pleural hemorrhage, Continued pleural hemorrhage, i.e. more than 200 mL/hour and i.e. more than 200 mL/hour and shows no signs of slowingshows no signs of slowing is is another indication for immediate another indication for immediate thoracotomy or video-assisted thoracotomy or video-assisted thoracic surgery (VATS). thoracic surgery (VATS).

The four main pleural The four main pleural complications of traumatic complications of traumatic hemothorax are the retention of hemothorax are the retention of clotted blood in the pleural clotted blood in the pleural space, pleural infection, pleural space, pleural infection, pleural effusion, and fibrothorax.effusion, and fibrothorax.


Catamenial HemothoraxCatamenial Hemothorax

Catamenial hemothorax is a hemothorax Catamenial hemothorax is a hemothorax that occurs in conjunction with that occurs in conjunction with menstruation and it is unusual. menstruation and it is unusual.

It is associated with pelvic abdominal and It is associated with pelvic abdominal and pleurapleura endometriosis.endometriosis.

Catamenial hemothorax can be treated by Catamenial hemothorax can be treated by suppressing ovulation using oral suppressing ovulation using oral contraceptives or progesterone or contraceptives or progesterone or suppression of gonadotropins using suppression of gonadotropins using danazol or gonadotropin releasing danazol or gonadotropin releasing hormone.hormone.


Hormonal therapy frequently Hormonal therapy frequently fails. fails.

So chemical pleurodesis can be So chemical pleurodesis can be performed, and if this measure performed, and if this measure fails, total hysterectomy with fails, total hysterectomy with bilateral oophorectomy can be bilateral oophorectomy can be done.done.

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