Pleural Effusion-Hemothorax

Definition

  • Hemothorax: pleural Hct >50% of serum Hct

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
  • 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
  • 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]])

Physiology

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

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)

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, [[]])

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

References

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