Clinical Manifestation

a. Clinical History
The individual or family member will give a history of blunt injury to the
chest such as from an automobile accident or penetrating wound (such as from
gunshot). In the absence of an obvious wound, the individual may also complain of
shortness of breath and moderate to severe chest pain. A few patients with
spontaneous pneumothorax develop hemothorax.
Symptoms of hemothorax are nonspesific and are similar to pleural effusion of
other causes. Patients typically have chest pain or dypsnea following blunt or
penetrating chest trauma. The history of trauma, however, may be subtle. Patients
with multisystem trauma may not complain of chest symptoms if other distracting
injuries are present. Dyspnea and chest discomfort are also common in nontraumatic
hemothorax. However, nontraumatic hemothorax may also be associated primarily
with nonrespiratory compalaints related to the underlying problem. Unilateral or
bilateral effusions in this setting are often found incidentally or chest radiography.
The patient with hemothorax may experience chest pain, tachypnea, and mild
to severe dyspnea, depending on the amount of blood in the pleural cavity and
associated pathologic conditions. If respiratory failure results, the patient may appear
anxious, restless, possibly stuporous, and cyanotic; marked blood loss produces
hypotension and shock. The affected side of the chest expands and stiffens, whereas
the unaffected side rises and falls with the patient’s breaths.
Signs of hemothorax may be evident with chest x-ray, removal of fluid
through a needle from the pleural cavity (thoracentesis), and visual or microscopic
analysis of this fluid (pleural fluid analysis). CT scanning may be complementary to
chest x-ray for precisely identifying location of fluid or blood clots.

b. Clinical Examination
In the physical examination is found tachypnoe, most individuals have
diminished ipsilateral breath sounds and a dull percussion note. The physician may
also note dulled sounds while tapping over the involved area. The individual may be
anxious and restless and have a rapid heartbeat. If substantial systemic blood loss has
occurred , hypotension and tachycardia are present.
(http://www.mdguidelines.com/hemothorax-traumatic).
Differential Diagnose
Pleural fluid appears bloody when it has a hematocrit of less than 5%. The
differential diagnosis of bloody appearing pleural fluid includes hemothorax,
hemorraghic effusion, and traumatic thoracentesis. All body effusions should be
analyzed for cell count and pleural fluid hematocrit to differential among these
conditions.
DIAGNOSTIC THORACENTESIS
↓
BLOODY FLUID
↓
Check Ht

≥ 50% peripheral blood < 50% peripheral blood

Evidence trauma? Measure

RBC
ccount

No
Yes > 105 RBC/μl < 105 RBC/μl
Chest tube
Chest tube Trauma Evaluate for
evaluate for:
Consider Malignancy other causes of
Malignancy
VATS Pulmonary pleural
Vascular
embolism effusions
Spontaneous
Postcardiac
Gynecologic
injury Thoracentesis

Distinguishing between true bloody effusions and traumatic thoracentesis can

be challenging. Traumatic thoracentesis is suggested by nonuniform color of fluid
during aspiration, clotting within minutes aspiration, and absence of pleural
hemosiderin-laden macrophages. The differential diagnosis of hemorraghic effusions
includes trauma, neoplasm, pulmonary embolism, postcardiac injury/ surgery, ang
asbestosis.
Work-Up
a. Laboratory findings
Pleural fluid analysis is nonspesific except for elevated red blood cell conuts.
True hemothorax is associated with a pleural fluid hematocrit that is 50% od greater
than that of peripheral blood.

b. Imaging Studies

Chest trauma is associated with significant morbidity and mortality in the pediatric
population.The following studies may be indicated in patients with suspected
hemothorax:

1. Radiography

Plain radiography of the upright chest may be adequate to establish diagnosis

by blunting at the costophrenic angle or an air-fluid interface if a hemopneumothorax
is present. If the patient cannot be positioned upright, a supine chest radiograph may
reveal apical capping of fluid surrounding the superior pole of the lung. A lateral
extrapulmonary density may suggest fluid in the pleural space.

2. CT scanning

Thoracic CT scanning has a definite role in evaluation, particularly if plain

radiography results are ambiguous or initial therapy is inadequate. CT scanning is
particularly helpful in localizing loculated collections of blood.

3. Bedside ultrasonography

Even with the use of chest radiography and helical CT, some injuries can
remain undetected. In particular, patients with penetrating chest injuries may harbor
serious cardiac injury and a pericardial effusion that may be clinically difficult to
determine.

Bedside echocardiography can provide immediate, accurate information

regarding the pericardium and the need for immediate surgery. It can also improve
patient outcome.
Treatment

a. Medical Care

Prehospital care in patients with hemothorax :

a) Assess airway, breathing, and circulation. Evaluate for the possibility of

tension pneumothorax. Assess vital signs and pulse oximetry. Administer
oxygen and establish an intravenous line.
b) Needle decompression of a tension pneumothorax may be necessary.
c) Initial treatment is directed to cardiopulmonary stabilization and evacuation of
the pleural blood collection.
d) If the patient is hypotensive, establish a large-bore intravenous line.
Commence appropriate fluid resuscitation with blood transfusion as necessary.
e) To evacuate, place a large-bore thoracotomy tube directed toward the
costophrenic angle.
f) If a conventional chest tube is not removing the blood collection, further steps
may be necessary. Conventional treatment involves placement of a second
thoracostomy tube. However, in many patients, this therapy is ineffective,
necessitating further intervention.
g) Video-assisted thoracoscopy (VATS) is an alternative treatment that permits
direct removal of clot and precise placement of chest tubes. VATS is
associated with fewer postoperative complications and shorter hospital stays
compared with thoracostomy.

Emergency department care :

a) The patient should be sitting upright unless other injuries contraindicate this
position. Administer oxygen and reassess airway, breathing, and circulation.
b) Obtain an upright chest radiograph as quickly as possible.
c) If the patient is hemodynamically unstable, immediately commence fluid
resuscitation (eg, 20 mL/kg of lactated Ringer solution).
 d) The need for a chest tube in an asymptomatic patient is unclear, but if the
patient has any respiratory distress, direct the large-bore chest tube toward the
costophrenic angle as the chest radiograph indicates.
e) A recent innovation is intrapleural fibrinolytic treatment of traumatic clotted
hemothorax. Either 250,000 units of streptokinase or 100,000 units of
urokinase was instilled daily into intrapleural space on 2-15 occasions. The
overall success rate was 92%.
f) Finally, if a fibrothorax develops despite previously mentioned therapeutic
modalities, a decortication procedure may be necessary to permit lung
expansion and reduce the risk of empyema

b. Medication

a) No data support routine antibiotic coverage of chest tubes in patients with

hemothorax.
b) Pain control may require intravenous opioid analgesic agents, intracostal nerve
blocks around the chest tube site, or both. Low suction should be used on the
chest tube

Complications

Complications of hemothorax include infection, fibrothorax, inadequate

removal of clotted blood, and pleural effusion. Empyema occurs in up to 5% of
hemothoraces. Empiric antibiotic, generally first-generation cephalosporins, decrease
the incidence of empyema in patients with traumatic hemothorax managed with tube
thoracostomy. Condition associated with an increased risk of empyema following
hemothorax include contamination of pleural space at the time of initial injury,
circulatory shock on presentation, concomitant abdominal injury, and prolonged chest
tube drainage. Fibrothorax is diffuse pleurl thickening that occurs as aresult of an
inflammatory reaction to blood in the pleural space. It is rare and typically develops
weeks to month after initial injury. Fibrithorax requires surgical decortication for
definitive management. Pleural effusions occur in 10-30% of patients with
hemothorax following removal of thoracostomy tubes. Diagnostic thoracentesis for
culture is recommended in patients who develop a postthoracostomy tube pleural
effusion to exclude underlying infection. Clinical observation is appropriate if no
infection is present.

Prognosis

If the individual has no additional serious wounds or illnesses and received the
described therapy, complete recovery is likely. The outcome after surgery for the
otherwise healthy individual is excellent. If treatment is unavailable or not started
promptly to stop blood leakage, respiratory failure and death likely will result. The
outcome is not predictable if the individual sustained serious wounds other than the
hemothorax.

Rehabilitation

Individuals who suffer from traumatic hemothorax will either require the
placement of a chest tube or a thoracotomy. Either of these procedures will necessitate
occupational, physical, and respiratory therapy. All therapies will begin in the
hospital, with physical therapy and possibly occupational therapy continuing after
discharge from the hospital 2 to 3 times a week for 6 weeks.

Respiratory therapy addresses increasing lung capacity and decreasing the risk
for the buildup of lung secretions. Respiratory therapists teach individuals pursed lip
breathing to increase the airflow to the lungs. Individuals may also use an incentive
spirometer, which is a device that measures and displays the amount of air inspired to
help motivate individuals to take deeper breaths. Individuals also learn to produce an
effective cough. Individuals learn to hold a pillow to the incision area when coughing,
laughing, or performing activity such as walking. This technique, called "splinting,"
can help alleviate pain at the incision site. Individuals learn positions to relieve
shortness of breath, and techniques to relieve pain at the incision site.

Occupational therapy addresses any fatigue or shortness of breath that may

occur during activities of daily living. Occupational therapists may also teach energy
conservation techniques, in which activities of daily living such as meal preparation
are broken up into smaller components, thereby making tasks more manageable.
 Physical therapy addresses decreased endurance, strength, and range of
motion. Because individuals often bend forward to alleviate pain at the site of a chest
tube or thoracotomy, they learn to stretch the shoulder and chest muscles to help
normalize posture. Individuals perform strengthening exercises of the arms and legs to
improve overall endurance, and of the upper back to promote normal posture.
Individuals also strengthen the diaphragm by lying on the back and performing
abdominal breathing exercises. Individuals may perform aerobic activity such as
walking on a treadmill or riding a stationary bicycle to further increase endurance.