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Hemothorax
Author:MaryCMancini,MD,PhD,MMMChiefEditor:JeffreyCMilliken,MDmore...
Updated:Dec17,2015

Background
Hemothoraxisthepresenceofbloodinthepleuralspace.Thesourceofbloodmay
bethechestwall,lungparenchyma,heart,orgreatvessels.Althoughsomeauthors
statethatahematocritvalueofatleast50%isnecessarytodifferentiatea
hemothoraxfromabloodypleuraleffusion,mostdonotagreeonanyspecific
distinction.
Hemothoraxisusuallyaconsequenceofbluntorpenetratingtrauma.Muchless
commonly,itmaybeacomplicationofdisease,maybeiatrogenicallyinduced, [1]or
maydevelopspontaneously. [2]
Promptidentificationandtreatmentoftraumatichemothoraxisanessentialpartof
thecareoftheinjuredpatient.Theuprightchestradiographistheidealprimary
diagnosticstudyintheevaluationofhemothorax(seeWorkup).Incasesof
hemothoraxunrelatedtotrauma,acarefulinvestigationfortheunderlyingsource
mustbeperformedwhiletreatmentisprovided.
Tubethoracostomydrainageistheprimarymodeoftreatment.Videoassisted
thoracoscopicsurgery(VATS)maybeused.Thoracotomyistheprocedureofchoice
forsurgicalexplorationofthechestwhenmassivehemothoraxorpersistent
bleedingispresent.(SeeTreatment.)

Historicalbackground
Hemorrhagefromorwithinthechesthasbeendetailedinnumerousmedical
writingsdatingbacktoancienttimes.Whilelesserformsoftraumawerecommonly
treatedintheancientphysician'sdailypractice,majorinjuries,especiallythoseto
thechest,weredifficulttotreatandoftenlethal.
Bythe18thcentury,sometreatmentforhemothoraxwasavailablehowever,
controversyragedaboutitsform.Anumberofsurgeons,includingJohnHunterin
1794,advocatedthecreationofanintercostalincisionanddrainageofthe
hemothorax.Thoseoftheopposingviewpointbelievedthatclosureofchestwounds
withoutdrainageandotherconservativeformsofmanagementofbloodycollections
inthechestwerepropertreatment.
WhileHunter'smethodwaseffectiveinevacuatingthehemothorax,thecreationof
aniatrogenicpneumothoraxasaresultoftheprocedurewasassociatedwith
significantmorbidity.Ontheotherhand,woundclosureorconservative
managementposedthepossiblerisksofsubsequentempyemawithsepsisor
persistenttrappedlungwithpermanentreductionofpulmonaryfunction.
Observingtheadvantagesanddangersofbothformsoftherapy,Guthrie,inthe
early1800s,gavecredencetobothviewpoints.Heproposedtheimportanceofearly
evacuationofbloodthroughanexistingchestwoundatthesametime,heasserted
thatifbleedingfromthechestpersisted,thewoundshouldbeclosedinthehope
thatexistingintrathoracicpressurewouldhaltthebleeding.Ifthedesiredeffectwas
accomplished,headvisedthatthewoundbereopenedseveraldayslaterforthe
evacuationofretainedclottedbloodorserousfluid.
Bythe1870s,earlyhemothoraxevacuationbytrocarandcannulaorbyintercostal
incisionwasconsideredstandardpractice.Notlongafterthis,underwaterseal
drainagewasdescribedbyanumberofdifferentphysicians.Thisbasictechnique
hasremainedthemostcommonformoftreatmentforhemothoraxandotherpleural
fluidcollectionstothisday. [3]

Anatomy
Normally,thepleuralspace,whichisbetweentheparietalandvisceralpleurae,is
onlyapotentialspace.Bleedingintothepleuralspacemayresultfromeither
extrapleuralorintrapleuralinjury.

Extrapleuralinjury
Traumaticdisruptionofthechestwalltissueswithviolationofthepleuralmembrane
cancausebleedingintothepleuralcavity.Themostlikelysourcesofsignificantor
persistentbleedingfromchestwallinjuriesaretheintercostalandinternal
mammaryarteries.Innontraumaticcases,rarediseaseprocesseswithinthechest
wall(eg,bonyexostoses)canberesponsible.

Intrapleuralinjury
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Bluntorpenetratinginjuryinvolvingvirtuallyanyintrathoracicstructurecanresultin
hemothorax.Massivehemothoraxorexsanguinatinghemorrhagemayresultfrom
injurytomajorarterialorvenousstructurescontainedwithinthethoraxorfromthe
heartitself.Theseincludetheaortaanditsbrachiocephalicbranches,themainor
branchpulmonaryarteries,thesuperiorvenacavaandthebrachiocephalicveins,
theinferiorvenacava,theazygosvein,andthemajorpulmonaryveins.
Injurytotheheartcanproduceahemothoraxifacommunicationexistsbetweenthe
pericardiumandthepleuralspace.
Injurytothepulmonaryparenchymamaycausehemothorax,butitisusuallyself
limitedbecausepulmonaryvascularpressureisnormallylow.Pulmonary
parenchymalinjuryisusuallyassociatedwithpneumothoraxandresultsinlimited
hemorrhage.
Hemothoraxresultingfrommetastaticmalignantdiseaseisusuallyfromtumor
implantsthatseedthepleuralsurfacesofthethorax.
Diseasesofthethoracicaortaanditsmajorbranches,suchasdissectionor
aneurysmformation,accountforalargepercentageofspecificvascular
abnormalitiesthatcancausehemothorax.Aneurysmsofotherintrathoracicarteries
suchastheinternalmammaryarteryhavebeendescribedandarepossiblecauses
ofhemothoraxifruptureoccurs.
Avarietyofunusualcongenitalpulmonaryabnormalities,includingintralobarand
extralobarsequestration, [4]hereditarytelangiectasia,andcongenitalarteriovenous
malformations,cancausehemothorax.
Hemothoraxcanresultfromapathologicprocesswithintheabdomenifblood
escapingfromthelesionisabletotraversethediaphragmthroughoneofthe
normalhiatalopeningsoracongenitaloracquiredopening.

Pathophysiology
Bleedingintothepleuralspacecanoccurwithvirtuallyanydisruptionofthetissues
ofthechestwallandpleuraortheintrathoracicstructures.Thephysiologicresponse
tothedevelopmentofahemothoraxismanifestedintwomajorareas:
hemodynamicandrespiratory.Thedegreeofhemodynamicresponseisdetermined
bytheamountandrapidityofbloodloss.

Hemodynamicresponse
Hemodynamicchangesvary,dependingontheamountofbleedingandtherapidity
ofbloodloss.Bloodlossofupto750mLina70kgmanshouldcauseno
significanthemodynamicchange.Lossof7501500mLinthesameindividualwill
causetheearlysymptomsofshock(ie,tachycardia,tachypnea,andadecreasein
pulsepressure).
Significantsignsofshockwithsignsofpoorperfusionoccurwithlossofblood
volumeof30%ormore(15002000mL).Becausethepleuralcavityofa70kgman
canhold4Lofbloodormore,exsanguinatinghemorrhagecanoccurwithout
externalevidenceofbloodloss.

Respiratoryresponse
Thespaceoccupyingeffectofalargeaccumulationofbloodwithinthepleural
spacemayhampernormalrespiratorymovement.Intraumacases,abnormalitiesof
ventilationandoxygenationmayresult,especiallyifassociatedwithinjuriestothe
chestwall.
Alargeenoughcollectionofbloodcausesthepatienttoexperiencedyspneaand
mayproducetheclinicalfindingoftachypnea.Thevolumeofbloodrequiredto
producethesesymptomsinagivenindividualvariesdependingonanumberof
factors,includingorgansinjured,severityofinjury,andunderlyingpulmonaryand
cardiacreserve.
Dyspneaisacommonsymptomincasesinwhichhemothoraxdevelopsinan
insidiousmanner,suchasthosesecondarytometastaticdisease.Bloodlossin
suchcasesisnotsoacuteastoproduceavisiblehemodynamicresponse,and
dyspneaisoftenthepredominantcomplaint.

Physiologicresolutionofhemothorax
Bloodthatentersthepleuralcavityisexposedtothemotionofthediaphragm,
lungs,andotherintrathoracicstructures.Thisresultsinsomedegreeofdefibrination
ofthebloodsothatincompleteclottingoccurs.Withinseveralhoursofcessationof
bleeding,lysisofexistingclotsbypleuralenzymesbegins.
Lysisofredbloodcellsresultsinamarkedincreaseintheproteinconcentrationof
thepleuralfluidandanincreaseintheosmoticpressurewithinthepleuralcavity.
Thiselevatedintrapleuralosmoticpressureproducesanosmoticgradientbetween
thepleuralspaceandthesurroundingtissuesthatfavorstransudationoffluidinto
thepleuralspace.Inthisway,asmallandasymptomatichemothoraxcanprogress
intoalargeandsymptomaticbloodypleuraleffusion.

Latephysiologicsequelaeofunresolvedhemothorax
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Twopathologicstatesareassociatedwiththelaterstagesofhemothorax:
empyemaandfibrothorax.Empyemaresultsfrombacterialcontaminationofthe
retainedhemothorax.Ifundetectedorimproperlytreated,thiscanleadto
bacteremiaandsepticshock.
Fibrothoraxresultswhenfibrindepositiondevelopsinanorganizedhemothoraxand
coatsboththeparietalandvisceralpleuralsurfaces.Thisadhesiveprocesstrapsthe
lunginpositionandpreventsitfromexpandingfully.Persistentatelectasisof
portionsofthelungandreducedpulmonaryfunctionresultfromthisprocess.

Etiology
Byfarthemostcommoncauseofhemothoraxistrauma.Penetratinginjuriesofthe
lungs,heart,greatvessels,orchestwallareobviouscausesofhemothoraxthey
maybeaccidental,deliberate,oriatrogenicinorigin. [5]Inparticular,centralvenous
catheterandthoracostomytubeplacementarecitedasprimaryiatrogeniccauses. [6,
7,8]

Bluntchesttraumacanoccasionallyresultinhemothoraxbylacerationofinternal
vessels. [9]Becauseoftherelativelymoreelasticchestwallofinfantsandchildren,
ribfracturesmaybeabsentinsuchcases. [10,11]
Thecausesofnontraumaticorspontaneoushemothoraxincludethefollowing:
Neoplasia(primaryormetastatic)
Blooddyscrasias,includingcomplicationsofanticoagulation
Pulmonaryembolismwithinfarction
Tornpleuraladhesionsinassociationwithspontaneouspneumothorax
Bullousemphysema
Necrotizinginfections
Tuberculosis
Pulmonaryarteriovenousfistulae
Hereditaryhemorrhagictelangiectasia [12]
Nonpulmonaryintrathoracicvascularpathology(eg,thoracicaorticaneurysm
oraneurysmoftheinternalmammaryartery)
Intralobarandextralobarsequestration [4]
Abdominalpathology(eg,pancreaticpseudocyst,splenicarteryaneurysm,or
hemoperitoneum)
Catamenial [13]
Casereportsinvolveassociateddisorderssuchashemorrhagicdiseaseofthe
newborn(eg,vitaminKdeficiency),HenochSchnleinpurpura,andbeta
thalassemia/hemoglobinEdisease. [14,15,16,17]Congenitalcysticadenomatoid
malformationsoccasionallyresultinhemothorax. [18]Acaseofmassivespontaneous
hemothoraxhasbeenreportedwithVonRecklinghausendisease. [19]Spontaneous
internalthoracicarteryhemorrhagewasreportedinachildwithtypeIVEhlers
Danlossyndrome.
Hemothoraxhasalsobeenreportedinassociationwithcostalcartilaginous
anomalies. [20,21,22,23]Ribtumorshaverarelybeenreportedinassociationwith
hemothorax.Intrathoracicruptureofanosteosarcomaofaribcausedhemorrhagic
shockina13yearoldgirl. [24]
Hemothoraxhasbeennotedtocomplicateasmallfractionofspontaneous
pneumothoraxcases.Althoughrare,itismorelikelytooccurinyoungadolescent
malesandcanbelifethreateningsecondarytomassivebleeding. [25]

Epidemiology
Quantifyingthefrequencyofhemothoraxinthegeneralpopulationisdifficult.A
verysmallhemothoraxcanbeassociatedwithasingleribfractureandmaygo
undetectedorrequirenotreatment.Becausemostmajorhemothoracesarerelated
totrauma,aroughestimateoftheiroccurrencemaybegleanedfromtrauma
statistics.
Approximately150,000deathsoccurfromtraumaeachyear.Approximatelythree
timesthisnumberofindividualsarepermanentlydisabledbecauseoftrauma,and
themajorityofthiscombinedgrouphavesustainedmultipletrauma.Chestinjuries
occurinapproximately60%ofmultipletraumacasestherefore,aroughestimateof
theoccurrenceofhemothoraxrelatedtotraumaintheUnitedStatesapproaches
300,000casesperyear. [26]
Ina34monthperiodatalargelevel1traumacenter,2086childrenyoungerthan
15yearswereadmittedwithbluntorpenetratingtrauma104(4.4%)hadthoracic
trauma. [27]Ofthepatientswiththoracictrauma,15hadhemopneumothorax(26.7%
mortality),and14hadhemothorax(57.1%mortality).Manyofthesepatientshad
othersevereextrathoracicinjuries.Nontraumatichemothoraxcarriesamuchlower
mortality.
Inanotherseriesofchildrenwithpenetratingchestinjuries(ie,staborgunshot
wounds),themorbiditywas8.51%(8of94). [28]Complicationsincludedatelectasis
(3),intrathoracichematoma(3),woundinfection(3),pneumonia(2),airleakfor
morethan5days(2),andsepticemia(1).Notethatthesestatisticsapplyonlyto
traumatichemothorax.

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Prognosis
Atpresent,thegeneraloutcomeforpatientswithtraumatichemothoraxisgood.
Mortalityassociatedwithcasesoftraumatichemothoraxisdirectlyrelatedtothe
natureandseverityoftheinjury.Morbidityisalsorelatedtothesefactorsandtothe
risksassociatedwithretainedhemothorax,namelyempyemaand
fibrothorax/trappedlung.Empyemaoccursinapproximately5%ofcases.
Fibrothoraxoccursinabout1%ofcases.
Retainedhemothoraxwithorwithoutoneoftheaforementionedcomplications
occursin1020%ofpatientswhosustainatraumatichemothorax,andmostof
thesepatientsrequireevacuationofthiscollection.Prognosisafterthetreatmentof
oneofthesecomplicationsisexcellent.
Shorttermandlongtermoutcomeforindividualswhodevelopanontraumatic
hemothoraxisdirectlyrelatedtotheunderlyingcauseofthehemothorax.
ClinicalPresentation

ContributorInformationandDisclosures
Author
MaryCMancini,MD,PhD,MMMProfessorandChiefofCardiothoracicSurgery,DepartmentofSurgery,
LouisianaStateUniversitySchoolofMedicineinShreveport
MaryCMancini,MD,PhD,MMMisamemberofthefollowingmedicalsocieties:AmericanAssociationfor
ThoracicSurgery,AmericanCollegeofSurgeons,AmericanSurgicalAssociation,SocietyofThoracicSurgeons,
PhiBetaKappa
Disclosure:Nothingtodisclose.
Coauthor(s)
ThomasScanlin,MDChief,DivisionofPulmonaryMedicineandCysticFibrosisCenter,Departmentof
Pediatrics,RutgersRobertWoodJohnsonMedicalSchool
ThomasScanlin,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheAdvancement
ofScience,SocietyforPediatricResearch,AmericanSocietyforBiochemistryandMolecularBiology,American
ThoracicSociety,SocietyforPediatricResearch
Disclosure:Nothingtodisclose.
DeniseSerebrisky,MDAssociateProfessor,DepartmentofPediatrics,AlbertEinsteinCollegeofMedicine
Director,DivisionofPulmonaryMedicine,LewisMFraadDepartmentofPediatrics,JacobiMedicalCenter
Director,JacobiAsthmaandAllergyCenterforChildren
DeniseSerebrisky,MDisamemberofthefollowingmedicalsocieties:AmericanThoracicSociety
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
ShreekanthVKarwande,MBBSChair,Professor,DepartmentofSurgery,DivisionofCardiothoracicSurgery,
UniversityofUtahSchoolofMedicineandMedicalCenter
ShreekanthVKarwande,MBBSisamemberofthefollowingmedicalsocieties:AmericanAssociationfor
ThoracicSurgery,AmericanCollegeofChestPhysicians,AmericanCollegeofSurgeons,AmericanHeart
Association,SocietyofCriticalCareMedicine,SocietyofThoracicSurgeons,WesternThoracicSurgical
Association
Disclosure:Nothingtodisclose.
ChiefEditor
JeffreyCMilliken,MDChief,DivisionofCardiothoracicSurgery,UniversityofCaliforniaatIrvineMedical
CenterClinicalProfessor,DepartmentofSurgery,UniversityofCalifornia,Irvine,SchoolofMedicine
JeffreyCMilliken,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AssociationforThoracicSurgery,AmericanCollegeofCardiology,AmericanCollegeofChestPhysicians,
AmericanCollegeofSurgeons,AmericanHeartAssociation,AmericanSocietyforArtificialInternalOrgans,
CaliforniaMedicalAssociation,InternationalSocietyforHeartandLungTransplantation,PhiBetaKappa,
SocietyofThoracicSurgeons,SWOG,WesternSurgicalAssociation
Disclosure:Nothingtodisclose.
AdditionalContributors
CharlesCallahan,DOProfessor,Chief,DepartmentofPediatricsandPediatricPulmonology,TriplerArmy
MedicalCenter
CharlesCallahan,DOisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,
AmericanCollegeofChestPhysicians,AmericanCollegeofOsteopathicPediatricians,AmericanThoracic
Society,AssociationofMilitarySurgeonsoftheUS,ChristianMedicalandDentalAssociations
Disclosure:Nothingtodisclose.
Acknowledgements

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TheauthorsandeditorsofMedscapeDrugs&Diseasesgratefullyacknowledgethecontributionsofprevious
authorsJaneMEggerstedt,MD,andAllenFagenholz,MD,tothedevelopmentandwritingofthesource
articles.

References
1.MayJ,AdesA.Porousdiaphragmsyndrome:haemothoraxsecondarytohaemoperitoneumfollowing
laparoscopichysterectomy.BMJCaseRep.2013Dec5.2013:[Medline].
2.TatebeS,KanazawaH,YamazakiY,AokiE,SakuraiY.Spontaneoushemopneumothorax.AnnThorac
Surg.1996Oct.62(4):10115.[Medline].
3.RuschVW,GinsbergRJ.Chestwall,pleura,lungandmediastinum.In:SchwartzSI,ed.Principlesof
Surgery.7thed.NewYork,NY:McGrawHill1999:667790:
4.DiCrescenzoV,LaperutaP,NapolitanoF,CarlomagnoC,GarziA,VitaleM.Pulmonarysequestration
presentedasmassivelefthemothoraxandassociatedwithprimarylungsarcoma.BMCSurg.2013Oct8.
13Suppl2:S34.[Medline].[FullText].
5.BroderickSR.Hemothorax:Etiology,diagnosis,andmanagement.ThoracSurgClin.2013Feb.23(1):89
96,vivii.[Medline].
6.JohnsonEM,SaltzmanDA,SuhG,DahmsRA,LeonardAS.Complicationsandrisksofcentralvenous
catheterplacementinchildren.Surgery.1998Nov.124(5):9116.[Medline].
7.WaddingtonMS,MullinsGC.Earlycomplicationofpediatriccentralvenouscannulation.PaediatrAnaesth.
2005Nov.15(11):10015.[Medline].
8.LesherAP,KratzJM,SmithCD.Removalofembeddedcentralvenouscatheters.JPediatrSurg.2008
Jun.43(6):10304.[Medline].
9.OtaH,KawaiH,MatsuoT.VideoAssistedMinithoracotomyforBluntDiaphragmaticRupturePresenting
AsaDelayedHemothorax.AnnThoracCardiovascSurg.2013Nov8.[Medline].
10.NakayamaDK,RamenofskyML,RoweMI.Chestinjuriesinchildhood.AnnSurg.1989Dec.210(6):7705.
[Medline].[FullText].
11.SharmaOP,HaglerS,OswanskiMF.Prevalenceofdelayedhemothoraxinbluntthoracictrauma.Am
Surg.2005Jun.71(6):4816.[Medline].
12.CottinV,ChinetT,LavolA,CorreR,MarchandE,ReynaudGaubertM,etal.Pulmonaryarteriovenous
malformationsinhereditaryhemorrhagictelangiectasia:aseriesof126patients.Medicine(Baltimore).
2007Jan.86(1):117.[Medline].
13.RoussetP,RoussetJablonskiC,AlifanoM,MansuetLupoA,BuyJN,RevelMP.Thoracicendometriosis
syndrome:CTandMRIfeatures.ClinRadiol.2013Dec10.[Medline].
14.SinniahD,NagalingamI.Hemothoraxinthenewborn.ClinPediatr(Phila).1972Feb.11(2):845.
[Medline].
15.HuybrechtsS,WojciechowskiM,PootS,VanReemptsP,RametJ.Hemothoraxaspresentationoflate
vitaminKdeficientbleedingina1montholdinfantwithhomozygousalpha1antitrypsindeficiency.EurJ
Pediatr.2007Oct.166(10):10812.[Medline].
16.HammoudehM,QaddoumiNK.PleuralhaemorrhageinHenochSchonleinpurpura.ClinRheumatol.1993
Dec.12(4):5389.[Medline].
17.TantraworasinA,SaetengS.Massivehemothoraxduetointrathoracicextramedullaryhematopoiesisina
patientwithbetathalassemiahemoglobinEdisease.JMedAssocThai.2013Jul.96(7):8669.[Medline].
18.LabergeJM,PuligandlaP,FlageoleH.Asymptomaticcongenitallungmalformations.SeminPediatrSurg.
2005Feb.14(1):1633.[Medline].
19.VaziriM,MehrazmaM.MassivespontaneoushemothoraxassociatedwithVonRecklinghausen'sdisease.
AnnThoracSurg.2006Oct.82(4):15001.[Medline].
20.PropperRA,YoungLW,WoodBP.Hemothoraxasacomplicationofcostalcartilaginousexostoses.Pediatr
Radiol.1980Apr.9(3):1357.[Medline].
21.TomaresSM,JabraAA,ConradCK,BeauchampN,PhoonCK,CarrollJL.Hemothoraxinachildasa
resultofcostalexostosis.Pediatrics.1994Mar.93(3):5235.[Medline].
22.JinW,HyunSY,RyooE,LimYS,KimJK.Costalosteochondromapresentingashaemothoraxand
diaphragmaticlaceration.PediatrRadiol.2005Jul.35(7):7069.[Medline].
23.CowlesRA,RoweDH,ArkovitzMS.Hereditarymultipleexostosesoftheribs:anunusualcauseof
hemothoraxandpericardialeffusion.JPediatrSurg.2005Jul.40(7):1197200.[Medline].
24.OsawaH,YoshiiS,TakahashiW,HosakaS,IshikawaN,MizutaniE,etal.Hemorrhagicshockdueto
intrathoracicruptureofanosteosarcomaoftherib.AnnThoracCardiovascSurg.2001Aug.7(4):2324.
[Medline].
25.KimES,KangJY,PyoCH,JeonEY,LeeWB.12yearexperienceofspontaneoushemopneumothorax.
AnnThoracCardiovascSurg.2008Jun.14(3):14953.[Medline].
26.RichardsonJD,MillerFB,CarrilloEH,SpainDA.Complexthoracicinjuries.SurgClinNorthAm.1996
Aug.76(4):72548.[Medline].
27.PecletMH,NewmanKD,EichelbergerMR,GotschallCS,GarciaVF,BowmanLM.Thoracictraumain
children:anindicatorofincreasedmortality.JPediatrSurg.1990Sep.25(9):9615discussion9656.

http://emedicine.medscape.com/article/2047916overview

5/6

3/19/2016

Hemothorax:Background,Anatomy,Pathophysiology

[Medline].
28.InciI,OzcelikC,NizamO,ErenN,OzgenG.Penetratingchestinjuriesinchildren:areviewof94cases.J
PediatrSurg.1996May.31(5):6736.[Medline].
29.BohosiewiczJ,KudelaG,KoszutskiT.ResultsofNussproceduresforthecorrectionofpectusexcavatum.
EurJPediatrSurg.2005Feb.15(1):610.[Medline].
30.IssaivananM,BaranwalP,AbrolS,BajwaG,BaldaufM,ShuklaM.Spontaneoushemopneumothoraxin
children:casereportandreviewofliterature.Pediatrics.2006Oct.118(4):e126870.[Medline].
31.ParryGW,MorganWE,SalamaFD.Managementofhaemothorax.AnnRCollSurgEngl.1996Jul.
78(4):3256.[Medline].[FullText].
32.MillerLA.Chestwall,lung,andpleuralspacetrauma.RadiolClinNorthAm.2006Mar.44(2):21324,viii.
[Medline].
33.MandaviaDP,JosephA.Bedsideechocardiographyinchesttrauma.EmergMedClinNorthAm.2004
Aug.22(3):60119.[Medline].
34.TrupkaA,WaydhasC,HallfeldtKK,NastKolbD,PfeiferKJ,SchweibererL.Valueofthoraciccomputed
tomographyinthefirstassessmentofseverelyinjuredpatientswithbluntchesttrauma:resultsofa
prospectivestudy.JTrauma.1997Sep.43(3):40511discussion4112.[Medline].
35.ChardoliM,HasanGhaliaeeT,AkbariH,RahimiMovagharV.Accuracyofchestradiographyversuschest
computedtomographyinhemodynamicallystablepatientswithbluntchesttrauma.ChinJTraumatol.2013
Dec1.16(6):3514.[Medline].
36.MooreMA,WallaceEC,WestraSJ.Theimagingofpaediatricthoracictrauma.PediatrRadiol.2009May.
39(5):48596.[Medline].
37.ChangYT,DaiZK,KaoEL,ChuangHY,ChengYJ,ChouSH,etal.Earlyvideoassistedthoracicsurgery
forprimaryspontaneoushemopneumothorax.WorldJSurg.2007Jan.31(1):1925.[Medline].
38.HenifordBT,CarrilloEH,SpainDA,SosaJL,FultonRL,RichardsonJD.Theroleofthoracoscopyinthe
managementofretainedthoraciccollectionsaftertrauma.AnnThoracSurg.1997Apr.63(4):9403.
[Medline].
39.LiuDW,LiuHP,LinPJ,ChangCH.Videoassistedthoracicsurgeryintreatmentofchesttrauma.J
Trauma.1997Apr.42(4):6704.[Medline].
40.ManciniM,SmithLM,NeinA,BuechterKJ.Earlyevacuationofclottedbloodinhemothoraxusing
thoracoscopy:casereports.JTrauma.1993Jan.34(1):1447.[Medline].
41.MeyerDM,JessenME,WaitMA,EstreraAS.Earlyevacuationoftraumaticretainedhemothoracesusing
thoracoscopy:aprospective,randomizedtrial.AnnThoracSurg.1997Nov.64(5):1396400discussion
14001.[Medline].
42.NavsariaPH,VogelRJ,NicolAJ.Thoracoscopicevacuationofretainedposttraumatichemothorax.Ann
ThoracSurg.2004Jul.78(1):2825discussion2856.[Medline].
43.InciI,OzelikC,UlkR,TunaA,ErenN.Intrapleuralfibrinolytictreatmentoftraumaticclotted
hemothorax.Chest.1998Jul.114(1):1605.[Medline].
44.[Guideline]DepartmentofSurgicalEducation,OrlandoRegionalMedicalCenter.Tissueplasminogen
activatorintraumatichemothorax.Availableat
http://www.surgicalcriticalcare.net/Guidelines/tissue_plasminogen_activator.pdf.Accessed:October14,
2014.
45.ChouYP,KuoLC,SooKM,TarngYW,ChiangHI,HuangFD,etal.Theroleofrepairinglunglacerations
duringvideoassistedthoracoscopicsurgeryevacuationsforretainedhaemothoraxcausedbybluntchest
trauma.EurJCardiothoracSurg.2013Nov15.[Medline].
46.ErnstgrdL,SjgrenB,GunnareS,JohansonG.Bloodandexhaledaircanbeusedforbiomonitoringof
hydrofluorocarbonexposure.ToxicolLett.2013Dec1.225(1):102109.[Medline].

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/2047916overview

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