Hemothorax_ Background, Anatomy, Pathophysiology.pdf

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3/19/2016 Hemothorax: Background, Anatomy, Pathophysiology

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Hemothorax

Author: Mary C Mancini, MD, PhD, MMM; Chief E ditor: Jeffrey C Milliken, MD more...

Updated: Dec 17, 2015

Background

Hemothorax is the presence of blood in the pleural space. The source of blood maybe the chest wall, lung parenchyma, heart, or great vessels. Although some authorsstate that a hematocrit value of at least 50% is necessary to differentiate ahemothorax from a bloody pleural effusion, most do not agree on any specificdistinction.

Hemothorax is usually a consequence of blunt or penetrating trauma. Much less

commonly, it may be a complication of disease, may be iatrogenically induced, [1] or

may develop spontaneously.[2]

Prompt identification and treatment of traumatic hemothorax is an essential part of he care of the injured patient. The upright chest radiograph is the ideal primary

diagnostic study in the evaluation of hemothorax (see Workup). In cases of hemothorax unrelated to trauma, a careful investigation for the underlying sourcemust be performed while treatment is provided.

Tube thoracostomy drainage is the primary mode of treatment. Video-assisted

horacoscopic surgery (VATS) may be used. Thoracotomy is the procedure of choicefor surgical exploration of the chest when massive hemothorax or persistentbleeding is present. (See Treatment.)

Historical background

Hemorrhage from or within the chest has been detailed in numerous medicalwritings dating back to ancient times. While lesser forms of trauma were commonlyreated in the ancient physician's daily practice, major injuries, especially those tohe 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 in1794, advocated the creation of an intercostal incision and drainage of thehemothorax. Those of the opposing viewpoint believed that closure of chest woundswithout drainage and other conservative forms of management of bloody collectionsin the chest were proper treatment.

hile Hunter's method was effective in evacuating the hemothorax, the creation of an iatrogenic pneumothorax as a result of the procedure was associated withsignificant morbidity. On the other hand, wound closure or conservativemanagement posed the possible risks of subsequent empyema with sepsis or persistent trapped lung with permanent reduction of pulmonary function.

Observing the advantages and dangers of both forms of therapy, Guthrie, in theearly 1800s, gave credence to both viewpoints. He proposed the importance of earlyevacuation of blood through an existing chest wound; at the same time, he assertedhat if bleeding from the chest persisted, the wound should be closed in the hopehat existing intrathoracic pressure would halt the bleeding. If the desired effect was

accomplished, he advised that the wound be reopened several days later for theevacuation of retained clotted blood or serous fluid.

By the 1870s, early hemothorax evacuation by trocar and cannula or by intercostalincision was considered standard practice. Not long after this, underwater sealdrainage was described by a number of different physicians. This basic techniquehas remained the most common form of treatment for hemothorax and other pleural

fluid collections to this day.[3]

Anatomy

Normally, the pleural space, which is between the parietal and visceral pleurae, isonly a potential space. Bleeding into the pleural space may result from either extrapleural or intrapleural injury.

Extrapleural injury

Traumatic disruption of the chest wall tissues with violation of the pleural membranecan cause bleeding into the pleural cavity. The most likely sources of significant or persistent bleeding from chest wall injuries are the intercostal and internalmammary arteries. In nontraumatic cases, rare disease processes within the chestwall (eg, bony exostoses) can be responsible.

Intrapleural injury







Two pathologic states are associated with the later stages of hemothorax:empyema and fibrothorax. Empyema results from bacterial contamination of theretained hemothorax. If undetected or improperly treated, this can lead tobacteremia and septic shock.

Fibrothorax results when fibrin deposition develops in an organized hemothorax andcoats both the parietal and visceral pleural surfaces. This adhesive process traps thelung in position and prevents it from expanding fully. Persistent atelectasis of portions of the lung and reduced pulmonary function result from this process.

Etiology

By far the most common cause of hemothorax is trauma. Penetrating injuries of thelungs, heart, great vessels, or chest wall are obvious causes of hemothorax; they

may be accidental, deliberate, or iatrogenic in origin.[5] In particular, central venous

catheter and thoracostomy tube placement are cited as primary iatrogenic causes. [6,

7, 8]

Blunt chest trauma can occasionally result in hemothorax by laceration of internal

vessels.[9] Because of the relatively more elastic chest wall of infants and children,

rib fractures may be absent in such cases. [10, 11]

The causes of nontraumatic or spontaneous hemothorax include the following:

Neoplasia (primary or metastatic)Blood dyscrasias, including complications of anticoagulationPulmonary embolism with infarctionTorn pleural adhesions in association with spontaneous pneumothoraxBullous emphysemaNecrotizing infectionsTuberculosisPulmonary arteriovenous fistulae

Hereditary hemorrhagic telangiectasia [12]

Nonpulmonary intrathoracic vascular pathology (eg, thoracic aortic aneurysmor aneurysm of the internal mammary artery)

Intralobar and extralobar sequestration [4]

Abdominal pathology (eg, pancreatic pseudocyst, splenic artery aneurysm, or hemoperitoneum)

Catamenial [13]

Case reports involve associated disorders such as hemorrhagic disease of thenewborn (eg, vitamin K deficiency), Henoch-Schönlein purpura, and beta

halassemia/hemoglobin E disease.[14, 15, 16, 17] Congenital cystic adenomatoid

malformations occasionally result in hemothorax.[18] A case of massive spontaneous

hemothorax has been reported with Von Recklinghausen disease. [19] Spontaneousinternal thoracic artery hemorrhage was reported in a child with type IV Ehlers-Danlos syndrome.

Hemothorax has also been reported in association with costal cartilaginous

anomalies.[20, 21, 22, 23]

Rib tumors have rarely been reported in association withhemothorax. Intrathoracic rupture of an osteosarcoma of a rib caused hemorrhagic

shock in a 13-year-old girl. [24]

Hemothorax has been noted to complicate a small fraction of spontaneouspneumothorax cases. Although rare, it is more likely to occur in young adolescent

males and can be life-threatening secondary to massive bleeding. [25]

Epidemiology

Quantifying the frequency of hemothorax in the general population is difficult. Avery small hemothorax can be associated with a single rib fracture and may goundetected or require no treatment. Because most major hemothoraces are relatedo trauma, a rough estimate of their occurrence may be gleaned from trauma

statistics.

Approximately 150,000 deaths occur from trauma each year. Approximately threeimes this number of individuals are permanently disabled because of trauma, and

he majority of this combined group have sustained multiple trauma. Chest injuriesoccur in approximately 60% of multiple-trauma cases; therefore, a rough estimate of he occurrence of hemothorax related to trauma in the United States approaches

300,000 cases per year.[26]

In a 34-month period at a large level-1 trauma center, 2086 children younger than15 years were admitted with blunt or penetrating trauma; 104 (4.4%) had thoracic

rauma. [27] Of the patients with thoracic trauma, 15 had hemopneumothorax (26.7%mortality), and 14 had hemothorax (57.1% mortality). Many of these patients hadother severe extrathoracic injuries. Nontraumatic hemothorax carries a much lower mortality.

In another series of children with penetrating chest injuries (ie, stab or gunshot

wounds), the morbidity was 8.51% (8 of 94).[28] Complications included atelectasis(3), intrathoracic hematoma (3), wound infection (3), pneumonia (2), air leak for more than 5 days (2), and septicemia (1). Note that these statistics apply only toraumatic hemothorax.







Prognosis

At present, the general outcome for patients with traumatic hemothorax is good.Mortality associated with cases of traumatic hemothorax is directly related to thenature and severity of the injury. Morbidity is also related to these factors and to therisks associated with retained hemothorax, namely empyema andfibrothorax/trapped lung. Empyema occurs in approximately 5% of cases.Fibrothorax occurs in about 1% of cases.

Retained hemothorax with or without one of the aforementioned complicationsoccurs in 10-20% of patients who sustain a traumatic hemothorax, and most of hese patients require evacuation of this collection. Prognosis after the treatment of

one of these complications is excellent.

Short-term and long-term outcome for individuals who develop a nontraumatichemothorax is directly related to the underlying cause of the hemothorax.

Clinical Presentation

Contributor Information and Disclosures

Author Mary C Mancini, MD, PhD, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery,Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American A ssociation for Thoracic Surgery, American College of Surgeons, American S urgical Association, Society of Thoracic Surgeons,Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)Thomas Scanlin, MD Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of

Pediatrics, Rutgers Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American A ssociation for the Advancementof Science, Society for Pediatric Research, American Society for Biochemistry and Molecular Biology, AmericanThoracic Society, Society for Pediatric Research


Denise Serebrisky, MD Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine;Director, Division of Pulmonary Medicine, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center;Director, Jacobi Asthma and Allergy Center for Children

Denise Serebrisky, MD is a member of the following medical societies: American Thoracic Society


Specialty Editor BoardFrancisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College

of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shreekanth V Karwande, MBBS Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery,University of Utah School of Medicine and Medical Center

Shreekanth V Karwande, MBBS is a member of the following medical societies: American A ssociation for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart

Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, Western Thoracic Surgical Association


Chief Editor Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine MedicalCenter; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega A lpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs,California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa,Society of Thoracic Surgeons, SWOG, Western Surgical A ssociation


Additional ContributorsCharles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler ArmyMedical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American ThoracicSociety, Association of Military Surgeons of the US, Christian Medical and Dental Associations


Acknowledgements

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http://www.acopeds.org/

http://www.chestnet.org/

http://www.aap.org/

http://www.westernsurgical.org/

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http://www.cmanet.org/

http://www.asaio.com/

http://www.heart.org/

http://www.facs.org/


http://www.cardiosource.org/

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The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previousauthors Jane M Eggerstedt, MD, and Allen Fagenholz, MD, to the development and writing of the sourcearticles.

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Hemothorax_ Background, Anatomy, Pathophysiology.pdf