Spontaneous hemothorax in hemophilia: case report and discussion of the hemophilia syndromes, with remarks on the management of hemothorax.
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Disease Management↗
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[Hemothorax with special reference to acute idiopathic hemothorax].
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Hemothorax↗
Hemothorax as a presenting symptom in abdominal pregnancy: markedly elevated chorionic gonadotropin titer findings associated with abdominal pregnancy and secondary hemothorax.
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Chorionic Gonadotropin↗
[The clinical approach to the isolated traumatic hemothorax.].
BACKGROUND: The aim of this study was to evaluate the systematic approach to the isolated traumatic hemothorax. MATERIAL AND METHODS: The treatment modalities of 103 cases with isolated hemothorax was analyzed retrospectively between 1995 and 2003. RESULTS: We observed 103 isolated hemothorax cases. Eighty eight of them were male and 15 were female. The mean age was 39.4 years. The hemothorax was left sided at 41 cases, right sided at 60 cases and bilateral at 2 cases. Fifty three (51,4%) penetrating, forty nine (47,5%) blunt, and one (0,9%) iatrogenic traumas with resultant hemothoraxes were investigated. We performed tube thoracostomy in ninety nine cases. One case required an urgent thoracotomy. We operated twenty one cases and thoracoscopy was performed for six of them. The conservative approach was sufficient for eighty two patients. Mortality was seen in only one case (0,9%), because of a multiorgan failure. The mean rate of the hospital stay was 8,7 days. During operation, we explored for major pulmonary and systemic artery injury. CONCLUSIONS: The decision of exploration or conservative treatment must be made according to the patient stabilization status after the thoracostomy tube insertion. Thoracoscopic evacuation of blood clots from hemothoraxes must be attempted during the early posttraumatic stages, especially in cases refractory to classical drainage methods.
Adolescent↗
[Treatment with intrapleural streptokinase for coagulated hemothorax after cardiac surgery with cardiopulmonary bypass].
INTRODUCTION AND OBJECTIVES: Coagulated hemothorax is a complication of cardiac surgery with cardiopulmonary bypass. The objective of this study was to present the authors' experience in the intrapleural infusion of streptokinase for the treatment of this complication. METHODS: From January 1996 to June 1999, nine patients (6 males, 3 females, age range: 1-75 years) were clinically and radiographically diagnosed with coagulated hemothorax after cardiac surgery. All patients were treated with intrapleural infusion of streptokinase at a standard dose of 250,000 units in adult patients and 12,000 U/kg in pediatric cases. In cases of occluded chest drainage, the position of the patient was changed and drainage was opened. RESULTS: In all the cases clinical and radiological improvement was observed and 100 to 200 ml of hemothorax was obtained on drainage. One patient died of multiorgan failure due to the underlying disease not related to the procedure. No alteration were observed in hematological tests including coagulation. The other 8 patients were discharged from hospital and remain without pulmonary compromise to date. CONCLUSION: Treatment of coagulated hemothorax with intrapleural infusion of streptokinase is a useful procedure and avoid the need for surgical drainage of hemothorax.
Adult↗
Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity.
OBJECTIVE: To describe the nature of delayed hemothorax occurring after blunt thoracic trauma and to identify the population at risk for this complication. METHODS: A retrospective review was conducted of 36 consecutive patients with hemothorax consequent to blunt trauma. Criteria for the definition of delayed hemothorax were established involving normal interval chest radiographs or computed tomographic scans during hospitalization. RESULTS: Twelve cases of delayed development of hemothorax were identified. Ninety-two percent of cases occurred in patients with multiple or displaced rib fractures. Presentation occurred from 18 hours to 6 days after injury. Eleven of the 12 cases were heralded by a prodrome of new pleuritic chest pain and dyspnea that occurred from 4 to 19 hours before treatment. CONCLUSION: Delayed hemothorax after blunt trauma is a unique entity occurring in patients with multiple or displaced rib fractures. Vigilance for the recognizable prodrome in the high-risk population should allow early remediation of this complication.
Aged↗
Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient.
BACKGROUND: The early removal of large residual posttraumatic hemothorax by videothoracoscopy is increasingly used to avoid the late sequelae of trapped lung and empyema. Plain chest radiography (CXR) is the tool most frequently used to select such cases for operation. Our recent experience has demonstrated that what appears to be a large retained hemothorax on CXR may turn out to be intrapulmonary or extrapleural conditions not amenable to thoracoscopic removal. Our objective was to evaluate the accuracy of CXR in detecting significant residual hemothorax and compare its clinical value to thoracic computed tomography (CT) when used to select patients for thoracoscopic evacuation. METHODS: All patients requiring tube thoracostomy for traumatic hemothorax were prospectively evaluated during a 22-month period (n = 703). Patients who, on the second day after admission, demonstrated opacification on CXR involving more than the costophrenic angle were evaluated by thoracic computed tomography for the presence of undrained fluid. Second-day CXR (CXR2) results were compared with the CT findings. Incorrect interpretation was defined as a difference of more than 300 mL between the two readings. All CXR2 and CT results were reviewed in the same fashion by a radiologist blinded to the surgeon's interpretations. Data on injury mechanism, hemodynamic status, laboratory values, interventions, and outcome were collected prospectively. RESULTS: Fifty-eight patients had clinically significant opacifications on CXR2. The surgeon's and radiologist's CXR2 interpretations were incorrect in 48 and 47% of the cases, respectively. The CT interpretations by the two specialists were in agreement in 97% of the cases. Management that would have been instituted on the basis of CXR2 findings was changed in 18 cases (31%). Twelve patients (21%) required early thoracoscopic evacuation of undrained collections. There was good correlation between the CT estimation and the thoracoscopically retrieved amount of blood. CONCLUSION: Although CXR is useful as a screening tool, it cannot be used to reliably select patients for surgical evacuation of retained traumatic hemothorax. Decision-making should be based on thoracic CT findings.
Adult↗
Hemothorax in 2 horses.
This report documents the successful conservative medical management of hemothorax in 2 horses. Hemothorax occurred after a lung biopsy procedure (horse 1) and strenuous exercise on a treadmill (horse 2). The horses had tachypnea, tachycardia, nostril flaring, hemoptysis, and pawing. Hemothorax was suspected based upon absence of auscultable ventral lung sounds; development of cool extremities and pale, tacky mucous membranes; the ultrasonographic appearance of moderate to severe amounts of pleural fluid; and a concurrent decrease in hematocrit and total plasma protein. Both horses were treated successfully by intranasal administration of oxygen, intravenous administration of balanced polyionic solutions, and treatment with antibiotics, nonsteroidal anti-inflammatory drugs, and analgesics. In neither case was pleural blood removed. The hemothorax resolved in both horses without lasting abnormalities. Hemothorax does not require drainage for successful resolution.
Analgesics↗
[Spontaneous hemothorax in a patient with lung metastases of osteosarcoma].
A 6-year-old girl with right lung metastases of osteosarcoma was scheduled for insertion of a central venous catheter and a femoral arterial catheter under general anesthesia for arterial injection chemotherapy. The central venous catheter was easily inserted through the right subclavian vein without arterial puncture. However, restlessness occurred on the first postoperative day. Chest X-ray examination revealed massive fluid collection in the right pleural space, which was identified as hemothorax by chest drainage. Chemotherapy started after the hemothorax had improved. However, restlessness occurred again on the 60 th postoperative day. Chest computed tomography examination revealed a right hemothorax and rupture of the growing lung metastatic tumor. Chest drainage was performed again. Some cases of pneumothorax complicated with rupture of lung metastases of osteosarcoma have been reported. Spontaneous rupture of lung metastases occurs regardless of tumor size, and occurs easily during chemotherapy because of necrosis of the tumor or disability of its repair function. In our case, rupture of the lung metastatic tumor involving tumor blood vessel was thought to have caused the hemothorax. Anesthesiologists should pay attention to spontaneous hemothorax in patients with lung metastases of osteosarcoma during whose perioperative management.
Child↗
Spontaneous hemothorax in patients with von Recklinghausen's disease.
Spontaneous massive intrathoracic bleeding is rare except for the rupture of aortic aneurysm or pleural adhesions in association with pneumothorax. We encountered two cases of critical massive hemothorax in patients with von Recklinghausen's disease (type I neurofibromatosis). Case 1; a 59-year-old female suddenly experienced severe back pain followed by syncope and shock. The hemothorax was caused by a bleeding of diffuse type neurofibroma of the parietal pleura and she underwent thoracotomy and surgical ligation of the bleeding vessels. Case 2; a 46-year-old male suddenly suffered back pain and fainted while driving. An intercostal aneurysmal rupture caused a spontaneous hemothorax and he underwent chest tube drainage followed by endovascular coil embolization. We reviewed 23 cases reported in the literature, including our two cases. Spontaneous hemothorax in patients with von Recklinghausen's disease is a life-threatening syndrome and may require emergency surgical or endovascular embolization.
Acute Disease↗
Reevaluation of early evacuation of clotted hemothorax.
During an 181/2 year period, we encountered 14,300 patients with blunt or penetrating thoracic or thoracicoabdominal trauma. In 155 patients, residual clotted hemothorax or empyema developed later. Thirty-nine patients underwent early evacuation of clotted hemothorax with no mortality and an average hospital stay of only 10 days. When progression to empyema occurred, the mortality rate increased to 9.4 percent and the average hospital stay to 37.9 days. The most common related event in the development of empyema was concurrent injury to intraabdominal organs and the inevitable bacterial contamination of the thorax. In a small number of patients, tube thoracostomy drainage is inadequate and results in residual clotted hemothorax. Despite recent pleas for conservative, expectant management, it is our experience that early evacuation of clotted hemothorax is not only cost-effective, it is also associated with lower morbidity, lower mortality, and reduces the chance of development of empyema.
Abdominal Injuries↗
[A rare complication of multiple exostoses: hemothorax].
BACKGROUND: Hemothorax is a rare complication of hereditary multiple exostosis. CASE REPORT: A 12 year-old boy suffered from abrupt thoracic pain, firstly attributed to pleural effusion. He had hereditary multiple exostosis known since the age of 9 years. The patients was given anti-inflammatory drugs and erythromycin but the pleural effusion became more abundant 6 days later requiring thoracentesis which showed hemothorax. All bacteriological and cytologic investigations were negative. X rays, ultra-sonography and CT scan showed several costal exostoses developing into the thoracic cavity. The hemothorax disappeared within 12 days and the patient was well 4 months later, without pleural sequelae. CONCLUSIONS: Hemothorax may be due to internal costal exostosis. It may be cured with thoracentesis; more aggressive therapy should be performed in exceptional cases with severe and/or recurrent bleeding.
Child↗
Occult traumatic hemothorax: when can sleeping dogs lie?
BACKGROUND: Size of traumatic occult hemothorax on admission requiring drainage has not been defined. Computed axial tomography (CAT) may guide drainage criteria. METHODS: A retrospective review of patients with hemothoraces on CAT was performed. Extrapolating previously described methods of pleural fluid measurement, hemothoraces were quantified using the fluid stripe in the dependent pleural "gutter." Data included patient age, injury severity, and intervention (thoracentesis or tube thoracostomy). RESULTS: Seventy-eight patients with 99 occult hemothoraces met the criteria for study inclusion: 52 hemothoraces qualified as "minimal" and 47 as "moderate/large." Eight patients (15%) in the minimal group and 31 patients (66%) in the moderate/large group underwent intervention (P < .001). There was no difference in patient age, injury severity, ventilator requirement, or presence of pulmonary contusion. CONCLUSIONS: CAT in stable blunt-trauma patients can predict which patients with occult hemothorax are likely to undergo intervention. Patients with hemothorax > or = 1.5 cm on CAT were 4 times more likely to undergo drainage intervention compared with those having hemothorax < 1.5 cm.
Adult↗
Use of intrapleural streptokinase in experimental minimal clotted hemothorax.
OBJECTIVE: In clotted hemothorax, both thoracocentesis and closed tube thoracostomy will not be able to evacuate the pleural cavity especially if it is minimal. The aim of this study was to assess the effectiveness of intrapleural administered streptokinase on minimal clotted hemothorax without drainage, in order to accelerate the spontaneous resolution and absorption in blunt thoracic trauma. METHODS: Thirteen adult ewes were used for this experiment. The animals were divided into two groups. First group served as the control group (Group C) (n=5) and did not receive any intrapleural fibrinolytic treatment. In both groups, 200 ml of blood was taken from the left jugular vein and injected into the pleural cavity with a serum line through the scope after pleural abrasion. Streptokinase (150.000 U) was diluted in 100 ml of saline and applied to the second group (Group S) (n=5) in second postoperative day. One ewe in each group was sacrificed with a lethal dose of sodium thiopental in postoperative 2nd, 4th, 6th, 8th, and 10th weeks, respectively. When a left posterolateral thoracotomy was performed, pleural thickening and adhesion were evaluated. The lung and pleural tissue samples were taken for histopathologic examination. The slides were examined in a blinded manner. RESULTS: Thoracentesis was performed in all ewes in the second postoperative day and no fluid was detected. There was no allergic reaction in group S after the injection of streptokinase into the pleural cavity. During postmortem macroscopic evaluation, we observed clot in one of the ewes in group C in second postoperative week. A statistically significant difference was found between Group C and S regarding pleural thickening and adhesion (P=0.05). The ewes of Group S had less pleural thickening and adhesion compared to those of Group C. These results were confirmed with histopathological examination. CONCLUSION: We conclude that intrapleural streptokinase increases resolution of clot in the pleural space and decreases pleural thickening and adhesion in experimental minimal clotted hemothorax in ewes. This study has also demonstrated that intrapleural streptokinase can be used without drainage. Use of intrapleural streptokinase without drainage can be a novel therapeutic option for trauma patients with minimal clotted hemothorax after haemorrhage of other organs was excluded.
Animals↗
Trauma ultrasound examination versus chest radiography in the detection of hemothorax.
STUDY OBJECTIVE: To compare the sensitivity, specificity, and accuracy of ultrasonography with those of the initial plain chest radiograph for detection of hemothorax in trauma patients. METHODS: Data from a prior prospective study of trauma ultrasonography at a Level I trauma center were retrospectively analyzed. The medical records of a convenience sample of adult patients who presented with major blunt or penetrating torso trauma during a 17-month period were reviewed. Emergency physicians performed a trauma ultrasound examination, which included evaluation for pleural fluid. Ultrasound interpretations were recorded before other diagnostic tests were obtained and were not used in patient management decisions. Records of the study patients were reviewed for confirmation of the presence or absence of hemothorax by other diagnostic and therapeutic interventions. The chest radiograph and computed tomography (CT) scan interpretations were performed by attending radiologists who were not blinded to patient outcome. RESULTS: Five of the 245 patients enrolled in the study were excluded because tube thoracostomy was performed before the ultrasound examination was done. Altogether, 26 of the 240 study patients had hemothorax, as confirmed by tube thoracostomy or CT. Both ultrasound examination and the initial chest radiograph resulted in 0 false-positive, 1 false-negative, 25 true-positive, and 214 true-negative findings. Overall, both modailties were 96.2% sensitive, 100% specific, and 99.6% accurate. CONCLUSION: Ultrasonography is comparable to the initial chest radiograph for accuracy in detection of hemothorax and may expedite the diagnosis and treatment of this condition for patients with major trauma.
Adult↗
Emergency department ultrasound for hemothorax after blunt traumatic injury.
Diagnosing hemothorax after blunt trauma may be aided by emergency department (ED) ultrasound (US). Various prior studies have evaluated ED US using different gold standards. A prospective study of blunt trauma patients who underwent computed tomography (CT) scan of the chest, abdomen, or both, was performed. Before CT scan, an US examination was performed specifically to identify free fluid in the thorax. The CT scan findings were used as the gold standard for validation of US results. From July 1998 to June 1999, 142 of 155 patients who underwent US and CT scan for evaluation of blunt trauma were included in this study. The CT scan identified 16 cases of hemothorax among these patients. ED US resulted in 2 true-positive, 2 false-positive, 14 false-negative, and 124 true-negative findings. ED US was 12.5% sensitive and 98.4% specific. ED US did not detect small-volume hemothorax identified by CT scan. Future research should focus on further defining the size of hemothorax appreciable with ED US, with increased attention paid to the type of gold standard implemented for its evaluation.
Cohort Studies↗
Follow-up chest radiographs after traumatic pneumothorax or hemothorax in the outpatient setting: a retrospective review.
PURPOSE: To evaluate the need for obtaining postdischarge chest radiographs for trauma patients who were treated with a thoracostomy tube. METHODS: A retrospective medical record review was conducted for all patients treated with a thoracostomy tube while admitted to the trauma service at Saint Louis University Hospital over a 12-month period. Patients who died during their hospital stay were excluded. RESULTS: During the 12-month study period, 155 trauma patients who were treated with a thoracostomy tube were discharged from the hospital. The indications for the thoracostomy tube were pneumothorax (n = 79, 51% of study population), hemopneumothorax (n = 34, 22%), hemothorax (n = 28, 18%), diaphragmatic rupture/laceration (n = 8, 5%), post thoracotomy (n = 4, 3%), and iatrogenic pneumothorax (n = 2, 1%). A follow-up clinic visit was scheduled for 1 to 2 weeks after discharge. Forty patients (26%) were lost to follow-up. Two patients called to report they had no symptoms and canceled their appointments. A total of 113 patients returned for follow-up appointments. Fifty-two patients had a predischarge chest radiograph that was negative for pneumothorax or hemothorax, had no symptoms, had normal results of a physical examination at the time of their clinic visit, and did not have a postdischarge chest radiograph. A total of 61 (54%) had postdischarge chest radiographs. Of that number, 56 (92%) were negative for pneumothorax. Three patients (5%) had a small pneumothorax, and 2 patients (3%) were noted to have a resolving hemothorax. All 5 patients were without symptoms and were released from the trauma service. CONCLUSION: A postdischarge chest radiograph is not indicated for an asymptomatic trauma patient who was treated with a tube thoracostomy and had a predischarge chest radiograph that was negative for pneumothorax or hemothorax.
Adolescent↗
Massive hemothorax complicating heparin anticoagulation for pulmonary embolus.
A case of massive hemothorax complicating heparin anticoagulation for pulmonary thromboembolism is presented. Hemothorax complicating anticoagulant therapy for PTE usually occurs within the first week of treatment and is invariably on the side of the initial clinical symptoms, suggesting intrapleural rupture of a hemorrhagic pulmonary infarct. Late hemothorax is unusual and may not be on the side of the initial symptoms, suggesting a different pathogenesis. Hemothorax may occur as the only bleeding complication of anticoagulation and when coagulation studies are within an acceptable therapeutic range. Cessation of anticoagulation therapy and prompt evacuation of the pleural space are recommended.
Hemothorax↗