Hemothorax is a collection of blood in the slit-like space, which is located between the visceral and parenteral lung pleura. This area is also called the pleural region, which normally contains serous fluid in small quantities. The Big Encyclopedic Dictionary characterizes hemothorax (derived from the Greek thorax - chest + haima - blood), as an accumulation of blood in the pleural cavity, due to internal bleeding.
When the pleural area is filled with blood due to a number of reasons, the lung is squeezed, and such organs as the thymus gland, the trachea, the aortic arch and its branches, the superior section of the vena cava with the main tributaries are displaced in the opposite direction.
Doctors isolated from the place of accumulation of blood and its hemothorax:
large or total hemothorax, when the arriving blood fills the pleural area completely,
apical - blood accumulates in the region of the apex of the lung,
small - the level of filling with blood does not reach the angle of the scapula,
interlobular - blood is in interlobar crevices,
supraphrenic - the blood is located in the pleural region adjacent to the diaphragm,
limited or encased - blood is in the pleural region, limited by adhesions,
parakostal - blood is located in the area near the ribs,
paramediation - blood is in the area adjacent to the mediastinal organs,
coagulated — accumulated blood underwent coagulation.
The severity of hemothorax and the overall clinical picture is determined depending on the volume of blood admitted to the pleural area, the total amount of blood loss, the degree of compression of the intrathoracic organs and the presence or absence of infection.
The most common cause of hemothorax is a chest injury, with a violation of the integrity of the blood vessels, but there are other factors that cause the accumulation of blood.
Causes of hemothorax
Experts identify several reasons leading to the development of a pathological condition, namely:
Occurrence of accumulation of blood due to closed or open injury of the chest. Most often they occur due to accidents, gunshot or knife wounds, rib fractures, falls from a height or other torsional injuries (according to statistics, in 70% of cases, injuries are right-sided). Blood in the pleural area accumulates due to damage to various organs of the thoracic (diaphragm, heart, lungs) or abdominal cavities (liver, spleen), as well as intercostal vessels, branches of the aorta or the internal thoracic artery.
Less common, but still common grounds for the occurrence of hemothorax, can become a variety of serious diseases. Tuberculosis and lung or pleural cancer, aortic aneurysm (expansion and then rupture of its area due to a number of reasons), benign and malignant neoplasms in the chest wall or in the mediastinum, hemorrhagic diathesis, pulmonary heart attack, impaired blood clotting (coagulopathy) - All these diseases can be pathological causes that can lead to the development of hemothorax.
Hemothorax may occur as a result of surgery, operations on the lungs and pleura, drainage of the pleural area, as a result of diagnostic or therapeutic pleural puncture (thoracocentesis), the installation of a catheter on the central veins. These are the so-called iatrogenic causes of hemothorax.
In general, the causes of hemothorax can be divided into three main groups: traumatic, pathological and iatrogenic.
Depending on the strength of bleeding, the amount of blood poured, the displacement of the organs of the medium and the compression of the lung, symptoms will be more or less pronounced:
If the hemothorax is small and the blood has not reached the level of the scapula, then the victim may complain of pain in the chest, which is aggravated during coughing, as well as slight shortness of breath.
When hemothorax large or medium-sized symptoms appear quite clearly. A person complains even with quiet breathing and a slight coughing at sharp, severe pains in the chest area radiating to the shoulder and back, there is general weakness, pressure drops, shallow breathing increases. Without treatment, the respiratory and cardiovascular disorders continue to aggravate, even with little exertion, the victim experiences severe pain, cannot be in a horizontal position, and is forced to take a sitting or semi-sitting position.
Severe hemothorax is characterized by symptoms such as: tachycardia, dizziness, fainting, cold sweat, severe pain in the chest area, anemia, and pale skin.
If hemothorax is accompanied by a fracture of the ribs, then subcutaneous emphysema, hematomas of soft tissues often occur, and hemoptysis appears when the lung is ruptured.
If the blood that has poured out is coagulated, the person feels severe shortness of breath and unbearable chest pain, the lung tissue undergoes sclerotic processes, the respiratory function is impaired.
When hemothorax is infected, fever appears with severe chills, lethargy, and general intoxication of the body.
Whatever the severity of hemothorax, there will always be a breathing disorder and pain in the chest area. To diagnose the severity and clarify the diagnosis, an x-ray or computed tomography is performed, which is a more reliable method of detecting accumulated blood. In addition, it is possible to additionally identify the cause of the hemothorax, for example, to detect a tumor. If necessary, doctors take a puncture accumulated blood, it allows you to detect bacteria or fungi, as well as cell type.
Modern methods of treatment can not only quickly identify, but also eliminate hemothorax. Naturally, the choice of methods of treatment will depend on the type of hemorrhage, the severity of symptoms, the causes of hemothorax.
Small hemothorax can be eliminated by conservative methods: symptomatic treatment is prescribed, immunocrection, antibiotics may be used, disaggregant therapy. Bleeding is promptly stopped. If a small amount of fluid has accumulated, then the human body is able to cope with this condition for about 2 weeks. But at the same time, the patient should be under constant control in order to exclude the possibility of re-bleeding or the occurrence of a bacterial infection.
If blood aspiration is required, thoracentesis or drainage of the affected area is performed. Antibiotics, antiseptics and proteolytic enzymes are introduced inside. Surgical intervention is carried out with coagulated hemothorax, in cases where the smoothing of the lung is impossible and the vital organs are affected. If large vessels are damaged, then the operation is carried out on an emergency basis by a thoracic surgeon.
The success of treatment depends on the type of injury or the nature of the disease that caused the hemothorax. Timely seeking medical help gives you more chances for successful elimination of the accumulated blood and for uncomplicated course of the disease. Hemothorax prophylaxis consists in preventing injuries and observing with a doctor if there is a risk of its occurrence due to various diseases.
Expert Editor: Pavel Alexandrovich Mochalov | D.M.N. general practitioner
Education: Moscow Medical Institute. I. M. Sechenov, specialty - “Medicine” in 1991, in 1993 “Occupational diseases”, in 1996 “Therapy”.
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Closed fractures of the VI, VII, VIII, IX ribs on the right. Right hemothorax
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Hemothorax (from ancient Greek αἷμα - blood and θώραξ - chest) - accumulation of blood in the pleural cavity. It is the result of bleeding from the vessels of the lungs, intrathoracic branches of large vessels (aorta, vena cava), chest wall, mediastinum, heart or diaphragm. Most often hemothorax occurs after chest trauma or as a complication of treatment.
Description of hemothorax due to injury of the chest is found already in the Middle Ages in Paracelsus, Ambroise Pare. For the first time, N. I. Pirogov gave evidence-based recommendations for the treatment of hemothorax. Up to the end of the 19th century, the tactics of treating hemothorax with “late” pleural punctures on 3-5th day after injury was common. Early pleural punctures entered into practice only during battles on the Khalkhin-Gol River (M. Apukhtin, A. A. Vishnevsky, 1939). Modern domestic principles of treatment of hemothorax developed by V.I. Kolesnikov, P.A. Kupriyanov, V.S. Levit during World War II.
Continuing internal bleeding with hemothorax leads to an accumulation of blood in the pleural cavity, which in turn causes compression of the lung on the affected side, and with further accumulation of blood - to a possible displacement of the mediastinum to the healthy side and compression of the healthy lung. As a result, there is a decrease in the volume of respiration, and consequently, in the respiratory surface of the lung and a violation of gas exchange. Displacement of the mediastinum with compression of the hollow veins and pulmonary vessels in turn has an adverse effect on hemodynamics. There is a clinic of acute respiratory and heart failure.
Fresh blood poured into the pleural cavity coagulates, but then as a result of fibrinolysis and mechanical defibrinating (“shaking up” due to respiratory movements) again becomes fluid. Sometimes fibrinolysis of coagulated blood does not occur, in such cases it develops coagulated hemothorax .
With the accumulation of blood in the isolated adhesions of the pleural sheets, the departments of the pleural cavity is formed limited hemothorax .
In the case of simultaneous accumulation of air and blood in the pleural cavity hemopneumothorax .
Symptoms and signs of hemothorax
The clinical picture in hemothorax depends on the volume of blood that has poured 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 structures of the mediastinum.
In a situation when there is a small hemothorax, the patient does not present active complaints, and the physical data are minimal or absent. In some cases, patients complain of the presence of dull pain in the affected half of the chest without irradiation, as well as difficulty breathing.
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 dagger pain in the half of the chest cavity with typical irradiation to the upper shoulder girdle and back, aggravated by the slightest movements of the chest and breathing. Hemodynamic disturbances are manifested in the form of hypotension and palpitations.
Signs of a severe degree of hemothorax are the development of symptoms of hypovolemic shock in the form of the onset of severe weakness, dizziness, and various degrees of disturbance of consciousness (fainting, spoor, coma).
In almost 70-80% of cases, traumatic hemothorax is caused by fractures of the ribs of different localization with displacement of bone fragments. In this situation, the main sign of violation of the integrity of the pulmonary parenchyma is the appearance of hemoptysis in a patient. Palpation of the chest causes a sharp pain and is determined by the pathological mobility of the costal frame. With marked displacement of bone fragments, there are signs of intermuscular and subcutaneous emphysema (the presence of soft tissue hematomas, as well as crepitus on palpation of soft tissues).
The coagulated hemothorax has no specific clinical manifestations and is characterized only by discomfort in the chest cavity during respiratory movements, as well as moderately pronounced respiratory disorders.
With long-term hemothorax, conditions are created for the infection of the pleural sheets and the development of the clinic for pleural empyema (febrile type of fever, intoxication syndrome, cough with the release of an abundant amount of purulent sputum).
Properly performed initial 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" under the condition of a known cause of its occurrence (a history of chest injury). At visual contact with the patient, pronounced pallor, increased humidity and decrease in the temperature of the skin are noteworthy. The damaged half of the rib cage is less actively involved in the act of breathing, localized swelling of the intercostal spaces on the affected side is possible. When making the percussion of the chest over the place of the supposed accumulation of blood (most often in the lower parts of the lung fields), a dull sound is determined, and the auscultative signs of hemothorax are the complete absence of vesicular respiration over the affected area.
Left-sided hemothorax with a large volume of blood in the pleural cavity is characterized by symptoms of displacement of those or other structures of the mediastinum, manifested as a shift in the boundaries of absolute cardiac dullness.
As a rule, hemothorax has a favorable outcome, which consists in resorption of residual blood clots in the pleural cavity, and the formation of small linear pleural moorings. This outcome of the disease is possible only if the treatment is adequately carried out 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 antibacterial therapy, can cause the development of infectious-toxic shock and even death.
Diagnosis of hemothorax
Among all known laboratory and instrumental methods for diagnosing hemothorax, the most appropriate are: ray 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 a trial of Rivilois-Gregoire and Petrov.
The easiest way to perform and in most cases informative in terms of the confirmation of hemothorax radiation method of diagnosis is a survey X-ray of the organs of the chest cavity. In order to diagnose a small amount of blood in one or another pleural cavity, it is recommended to perform X-ray in standing or lateroposition.
Depending on the volume of intrapleural hemorrhage, certain skalogichesky signs appear:
- the presence of blackout with a well-defined clear upper bound, homogeneous structure and increased intensity or total darkening throughout all lung fields,
- lack of a clear structure of the costo-diaphragmatic or cardio-diaphragmatic pleural sinuses,
- lack of visualization of the dome of the diaphragm on the affected side,
- displacement of mediastinal structures and varying degrees of lung collapse.
At X-ray examination, signs of limited hemothorax, which occur in patients suffering from adhesions of pleural cavities, can be detected. The limited hemothorax is visualized as a blackout with clear contours, a uniform structure and, as a rule, these changes are localized in the middle and lower pulmonary fields.
Standard radiography allows only to assess the presence of fluid level in the pleural cavity and presumably to reveal the volume of accumulated blood. Thus, the available 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 limit of the darkening is at the level of the posterior segment of the second rib, then the blood volume is from one to two liters. The lot of the ultrasound diagnostic specialist is to evaluate even a meager 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 carried out in order to establish the continuing bleeding and signs of infection of the pleural sheets. The criterion of an infected hemothorax is a positive test of Petrov, which reveals a decrease in transparency and the presence of precipitated aspirated blood. If an infection of the pleural cavity is suspected, it is necessary to perform not only cytological, but also bacterial examination of the aspirate. A decisive sign of continued intrapleural bleeding is the positive Rivilo-Greguard test, which implies signs of clotting of aspirated blood.
The most informative diagnostic method, allowing to diagnose a small amount of blood in the pleural cavity, as well as coagulated type of hemothorax, is diagnostic thoracoscopy. It should be borne in mind that for thoracoscopy, there must be strict indications: penetrating knife wound of the chest with localization below the seventh intercostal space (in order to exclude thoracoabdominal damage), injury of the mediastinum organs (heart and large vessels), the presence of a large volume of blood during pleurocentesis (more than 1 liters), pneumohemothorax.
Like any invasive manipulation, thoracoscopy has contraindications for use, among which should be noted such as: hemorrhagic shock, cardiac tamponade and obliteration of the pleural cavity.
Hemothorax is the second most common (after pneumothorax) complication of chest injuries and occurs in 25% of patients with thoracic injury. Quite often in clinical practice there is a combined pathology - hemopneumothorax. The danger of hemothorax lies in both the growing respiratory failure caused by compression of the lung and the development of hemorrhagic shock due to acute internal bleeding. In pulmonology and thoracic surgery, the hemothorax is regarded as an emergency condition requiring the provision of emergency specialized care.
Medical expert articles
Hemorrhage into the pleural cavity is a common type of complication of a closed or open chest injury. Most often, hemothorax (haemothorax) occurs as a result of rupture of the blood vessels of the chest wall or lung. The volume of hemorrhage while able to reach two liters or more.
With extensive hemothorax, the violation of the integrity of the intercostal arteries is more often recorded, less often - the aorta or other bulk vessels of the breast. This condition is considered dangerous, primarily due to the progressive compression of the lung and the development of respiratory failure, as well as due to massive blood loss.
Prognosis and prevention
The success of treatment of hemothorax is determined by the nature of the injury or disease, the intensity of blood loss and the timeliness of surgical care. The prognosis is most favorable in cases of small and medium uninfected hemothorax. A coagulated hemothorax increases the likelihood of developing pleural empyema. Continuing intrapleural bleeding or one-time large blood loss can lead to the death of the patient.
The outcome of hemothorax may be the formation of massive pleural adhesions, limiting the mobility of the dome of the diaphragm. Therefore, during the rehabilitation period, patients who have undergone hemothorax are recommended to practice swimming and breathing exercises. Hemothorax prophylaxis consists in preventing injuries, compulsory consultation of patients with thoraco-abdominal trauma by a surgeon, control of hemostasis during operations on the lungs and mediastinum, careful execution of invasive procedures.