Hemotorax is the accumulation of blood between the pleural sheets, resulting from bleeding from large pulmonary and intrathoracic vessels with injuries of the chest wall, diaphragm and mediastinal organs.
In contrast to pneumothorax, the mechanism of occurrence of which is similar to hemothorax, in the case of congestion of the blood in the pleural cavity, the symptoms of non-respiratory insufficiency come to the fore, and the hypovolemic symptom complex, which is often complicated by the development of signs of hemorrhagic shock and fatal outcome. But in most situations with open chest damage, signs of hemopneumothorax develop.
The frequency of occurrence of this pathology is at least 25% among all cases of thoracic trauma. Hemotorax refers to the category of urgent nosological diseases requiring early diagnosis and emergency medical intervention.
Causes of hemothorax
The most common etiopathogenetic factor of hemothorax emergence is traumatic closed thoracic cavity damage with damage to the bone skeleton. With this effect, there is a so-called "traumatic hemothorax".
An independent form of hemothorax is considered a postoperative type, which should not be regarded as iatrogenic effect. In the postoperative period, in patients with thoracotomy, coagulated hemothorax most often occurs, which does not pose a threat to the life of the patient. Very rarely hemothorax acts as a complication of pleural puncture or catheterization of the subclavian vein, when there is a slight damage to the vessel.
Some of the pathology of the thoracic cavity can be complicated by the development of hemothorax. These diseases include destructive forms of tuberculosis , malignant neoplasms of mediastinal and lung organs, pleural carcinomatosis, aneurysmal dilatation of the intrathoracic arterial vessels. In addition, chronic blood diseases with a violation of coagulative properties can provoke the development of hemothorax on the background of complete well-being.
Pathogenetic mechanisms of blood accumulation in the pleural cavities are the same for all types of hemothorax and are based either on a traumatic defect or on increased permeability of the vascular wall. The volume of accumulated blood depends not only on the degree of disruption of the integrity of the lung, but also on the location of the lesion. With damage to medium and small caliber vessels located in the peripheral parts of the lung, a small hemothorax develops. In a situation where the walls of large main vessels are damaged, total hemothorax develops, accompanied by severe hemodynamic disorders and death.
The development of the signs of coagulated hemothorax is due to massive intrapleural bleeding, in which the process of blood coagulation is most active in the first 4-5 hours from the beginning of bleeding. The risk of coagulated hemothorax increases in patients suffering from a violation of the coagulation properties of the blood.
Symptoms and signs of hemothorax
The clinical picture of hemothorax depends on the volume of blood flowing into the pleural cavity, the presence or absence of a violation of the integrity of the lung tissue, as well as the state of the mediastinal structures.
In a situation where there is a small hemothorax, the patient does not make active complaints, and the physical data is minimal or absent. In some cases, patients complain of the presence of blunt pain in the affected half of the chest without irradiation, as well as shortness of breath.
In case of damage to large-caliber vessels, the patient develops a typical symptom-complex, the characteristic manifestations of which are pronounced hemodynamic and respiratory disorders. In the prevailing majority, patients with hemothorax complain of acute daggerache in half of the thoracic cavity with a typical irradiation into the upper humeral girdle and back, which is strengthened with the slightest movements of the chest and with breathing. Hemodynamic disorders manifested in the form of hypotension and increased heart rate.
Signs of severe degree of hemothorax is the development of symptoms of hypovolemic shock in the form of pronounced weakness, dizziness , various degrees of impaired consciousness (fainting, sopor, coma).
Traumatic hemothorax almost in 70-80% of cases is caused by fractures of ribs of different localization with displacement of bone fragments. In this situation, the main sign of a violation of the integrity of the pulmonary parenchyma is the appearance of hemoptysis in the patient. Palpation of the chest causes severe soreness and the pathological mobility of the rib framework is determined. With a pronounced displacement of the bone fragments, there are signs of intermuscular and subcutaneous emphysema (the presence of soft tissue in the hematoma, as well as crepitation in the palpation of soft tissues).
Curated hemothorax has no specific clinical manifestations and is characterized only by discomfort in the thoracic cavity during respiratory movements, as well as by mild-expressed respiratory disorders.
With prolonged hemothorax, conditions are created for the infection of pleural sheets and the development of the clinic empyema of the pleura (febrile type of fever, intoxication syndrome, cough with the release of an abundant amount of purulent sputum).
Correctly performed primary examination of the patient with the use of all possible physical examination methods (palpation, percussion and auscultation of the lungs and heart) in almost 70% of cases can reliably establish the diagnosis of "hemothorax", provided a known cause of its occurrence (the presence of an injury in the chest cavity in the anamnesis). When visual contact with the patient draws attention to the expressed pallor, increased humidity and a decrease in the temperature of the skin. A damaged half of the chest is less active in the act of breathing, possibly the emergence of local bulging of the intercostal spaces on the side of the lesion. When percussion of the chest over the place of the alleged blood accumulation (most often in the lower parts of the pulmonary fields) blunt sound is determined, and auscultatory signs of hemothorax is the complete absence of vesicular breathing above the affected area.
Left-sided hemothorax with a large volume of blood in the pleural cavity is characterized by symptoms of displacement of various mediastinal structures, manifested as a displacement of the boundaries of absolute cardiac dullness.
As a rule, hemothorax has a favorable outcome, which consists in resorption of residual blood clots located in the pleural cavity, and the formation of small linear pleural cleavage. This outcome of the disease is possible only if the treatment is adequately performed in full. In some cases, hemothorax is accompanied by infection of the pleural cavity and the appearance of signs of pleural empyema, which in the absence of massive antibiotic therapy, can cause the development of an infectious-toxic shock and even death.
Diagnosis of hemothorax
Among all known laboratory and instrumental methods for diagnosing hemothorax, the most appropriate are: radiation imaging methods (fluoroscopy, ultrasound scanning of pleural cavities, computed tomography and magnetic resonance imaging), bronchoscopy with concomitant biopsy, sputum cytology to determine the presence of atypical cells, diagnostic thoracocentesis with the carrying out of Rivilua-Gregoire and Petrov.
The simplest in the performance and in most cases informative in terms of confirming hemothorax by the radiation method of diagnosis is an overview fluoroscopy of the thoracic cavity organs. In order to diagnose a small amount of blood in a pleural cavity, it is recommended that radiography be performed in a standing or later position.
Depending on the volume of intrapleural bleeding, there are some other signs of the skin:
- the presence of a darkening with an oblique superior upper boundary, a homogeneous structure and increased intensity or total darkening throughout all pulmonary fields;
- lack of a clear structure of bone-diaphragmatic or cardio-diaphragmatic pleural sinuses;
- lack of visualization of the dome of the diaphragm on the side of the lesion;
- displacement of mediastinal structures and a different degree of lung collagen.
Radiologic examination may reveal signs of limited hemothorax that occur in patients suffering from adhesions of the pleural cavities. Limited hemothorax is visualized as a darkening with clear contours, a homogeneous structure and, as a rule, these changes are localized in the middle and lower pulmonary fields.
Standard radiography allows only to estimate the presence of a level of fluid in the pleural cavity and presumably to reveal the volume of accumulated blood. Thus, the existing total darkening of the entire half of the chest indicates that there are at least two liters of blood in the pleural cavity, and if the upper border of the darkening is at the level of the posterior segment of the second rib, the volume of blood is from one to two liters. The specialty of ultrasound diagnostics is the evaluation of even a scant amount of blood.
After determining the presumptive presence of blood in the pleural cavity, it is advisable to produce a diagnostic pleurocentesis with aspiration of the contents of the pleural cavity. This manipulation is performed to establish the continuing bleeding and signs of infection of pleural sheets. The criterion of infected hemothorax is a positive Petrova test, at which a decrease in the transparency and the presence of a sediment of aspirated blood is detected. If a pleural cavity is suspected of infection, it is necessary to perform not only a cytological but also a bacterial study of the aspirate. A predetermining sign of continuing intrapleural bleeding is the positive test of Rivilua-Gregoire, which implies the presence of signs of coagulation of aspirated blood.
The most informative diagnostic method, which allows to diagnose a small amount of blood in the pleural cavity, as well as the coagulated type of hemothorax, is diagnostic thoracoscopy. It should be noted that for thoracoscopy, there must be strict indications: a penetrating knife wound of the chest with a localization below the seventh intercostal space (to exclude thoracoabdominal injury), injury to the mediastinal organs (heart and large vessels), the presence of a large volume of blood in the pleurocentesis (more than 1 liter), pneumothorax.
Like any invasive manipulation, thoracoscopy has contraindications to use, among which should be noted such as: hemorrhagic shock, cardiac tamponade and obliteration of the pleural cavity.
Treatment of hemothorax
Treatment of the patient with hemothorax should be dealt with by doctors of different profiles: surgeon, pulmonologist, angiologist and rehabilitologist.
The success of the use of certain therapeutic manipulations in hemothorax depends, first of all, on the early diagnosis of this life-threatening condition for the patient, as well as the timely provision of the first qualified care.
Treatment of any form of hemothorax should be carried out as early as possible, since blood is one of the most favorable nutrient media for the propagation of pathogens. The most common pathogens of infected hemothorax are obligate anaerobic flora.
Conservative methods of treatment with the use of antibacterial and anti-inflammatory drugs are used only in the case of small hemothorax, which does not have significant disorders of the patient's health. Conservative treatment should be performed under mandatory radiological monitoring. The optimal time for resolution of small hemothorax is from two weeks to one month. To accelerate the process of resorption of blood clots to patients with signs of coagulated hemothorax, it is advisable to assign proteolytic enzymes parenterally (Chymotrypsin 2.5 mg intramuscularly once a day with a course of at least 15 injections), and also by direct irrigation of the pleural cavities with solutions of Urokinase, Streptokinase.
The first help with hemothorax in the prehospital stage is to produce adequate analgesia with the use of 2 ml of a 50% solution of Analgin by intramuscular infusion, oxygen therapy. In a situation where there are signs of hypovolemic shock, it is advisable to immediately administer Reopoliglyukin 400 ml intravenously-drip.
A patient with signs of hemothorax is mandatory to be hospitalized in a surgical hospital for conducting instrumental diagnostic methods and determining adequate treatment tactics. It should be taken into account that the preferred method of transportation of the patient is evacuation on stretchers in the "half-sitting" position.
The presence of a large volume of blood in the pleural cavity, accompanied by a violation of the central hemodynamics, requires adequate cardiovascular drug therapy (Mesaton 1% solution in a dose of 2 ml by subcutaneous injection, 0.06% solution of Korglikona 1 ml dissolved in 10 ml isotonic solution of sodium chloride by the method of intravenous infusion).
In a situation where there is massive intrapleural bleeding, accompanied by posthemorrhagic anemia, the patient is recommended to perform a replacement transfusion of erythrocyte mass or whole blood in order to avoid the development of hypovolemic shock.
The algorithm of anti-shock measures for hemothorax consists in the following medical manipulations:
- the imposition of a tight bandage soaked in an antiseptic;
- providing access to oxygen;
- Carrying out a vagosympathetic novocaine blockade;
- Infusion therapy (40% solution of Glucose intravenously, 5 ml of 5% solution of ascorbic acid intravenously, Hydrocortisone 25-50 mg intramuscularly, 10% Calcium Chloride solution 10 ml intravenously).
In an inpatient setting, primary medical care consists in performing primary surgical treatment of the existing injuries of the thoracic cavity and in a situation where there are no signs of damage to the vital organs and structures of the chest cavity, hemostasis and suturing are performed. If there is damage to the organs of the chest, it is necessary to prepare the patient in an emergency order for an extended thoracotomy with concomitant damage suturing.
Absolute indication for an extended thoracotomy with the aim of establishing the localization and suturing of the existing lesion is the positive test of Rivilua-Gregoire, indicating the continuing bleeding into the pleural cavity.
After the creation of thoracotomy, drains with a diameter of 2-2.5 cm should be placed in the pleural cavity on the side of the lesion to further isolate the accumulating blood. The most suitable localization for the installation of drainage is the sixth intercostal space along the middle axillary line. Isolation of bloody fluid is an active or passive method. The indication for the removal of the drainage tube is the complete cessation of the discharge of fluid from the pleural cavity, and this manipulation is performed in compliance with the rules of antiseptic.
If there is no indication for thoracotomy, a pleurocentesis is performed to remove blood from the pleural cavity. The most physiological in this situation is the place for puncture is the seventh intercostal space in the back axillary line, however it is preferable to carry out a thoracentesis under the control of an ultrasound transducer. Pleural puncture is performed in order to eliminate increasing respiratory and hemodynamic disorders.
In the treatment of coagulated hemothorax and fibrotorax, which develops after ineffective drainage of the pleural cavity with the subsequent appearance of massive pleural clefts, the use of washing pleural cavities with proteolytic enzymes is ineffective. The only advisable method of surgical treatment of coagulated hemothorax is thoracotomy with concomitant antiseptic treatment of pleural cavities using solutions containing free iodine in a concentration of at least 10 g / l (Betadin, Yoks).
Thoracoscopy is performed not only for the purpose of visualization of the pleural cavities, but also for the separation of the spliced pleural sheets by the method of manual reception. After removing clots of coagulated blood, it is necessary to coagulate all the existing damages of the vascular wall with an electrocoagulator. Thus, videotoracoscopy is considered to be the most preferred diagnostic and therapeutic method with a curtailed hemothorax.
The rehabilitation period after surgical or conservative treatment should be aimed at eliminating possible complications and preventing the adhesion process in the pleural cavities. The patient is recommended to perform special respiratory gymnastics, as well as early motor activity in the postoperative period. To accelerate the spreading of lung tissue and prevent the emergence of pleural pleasures, patients who have undergone hemothorax, are recommended to engage in swimming and athletic walking.