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| '''For patient information, click [[Hemothorax (patient information)|here]]''' | | '''For patient information, click [[Hemothorax (patient information)|here]]''' |
| {{Hemothorax}} | | {{Hemothorax}} |
| {{CMG}} | | {{CMG}}; {{AE}} [[User:Irfan Dotani|Irfan Dotani]] {{JE}} |
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| {{SK}} Hematothorax; haemothorax | | {{SK}} Hematothorax; haemothorax |
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| {{Infobox_Disease
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| ==[[Hemothorax overview|Overview]]== | | ==[[Hemothorax overview|Overview]]== |
| Hemothorax as a clinico-pathological entity can be defined in two ways. Morphologically, it is a pathologic collection of blood within the [[pleural cavity]], between the [[lung]] surface and inner [[Thoracic cavity|chest wall]]. Clinically , hemothorax is defined as a pleural fluid with a [[hematocrit]] ranging from at least 25–50% of peripheral blood. In cases of long standing haemothorax due to [[haemodilution]], hemothorax can appear with lower levels of hematocrit. massive hemothorax is defined as the drainage of more than 1500 cc of blood upon [[chest tube]] insertion.
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| ==[[Hemothorax historical perspective|Historical Perspective]]== | | ==[[Hemothorax historical perspective|Historical Perspective]]== |
| haemothorax has been detailed in numerous medical writings dating back to ancient times. In 1794, the first intercostal incision was developed by John Hunter to treat and drainage of the hemothorax.
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| ==[[Hemothorax classification|Classification]]== | | ==[[Hemothorax classification|Classification]]== |
| Spontaneous haemothorax (SH) is a subcategory of haemothorax.
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| ==[[Hemothorax pathophysiology|Pathophysiology]]== | | ==[[Hemothorax pathophysiology|Pathophysiology]]== |
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| === Pathogenesis ===
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| Three mechanisms of bleeding in haemothorax:
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| * a torn adhesion between the [[Pleural cavity|parietal and visceral pleurae]].
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| * rupture of neovascularized bullae as a complication of subpleural emphysematous blebs.
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| * torn [[congenital]] aberrant vessels branching from the cupola and distributed in and around the bulla in the apex of the lung.
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| === Genetics ===
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| * [[Ehlers-Danlos syndrome]] (EDS) forms part of a spectrum of genetically based [[connective tissue disorders]] that includes [[osteogenesis imperfecta]]. [[Ehlers-Danlos type IV syndrome|Vascular Ehlers-Danlos syndrome (EDS IV)]] is characterized by an alteration in the [[Ehlers-Danlos syndrome|COL3A1 gene]]. This gene encodes type III [[collagen]] and The alteration of this type of collagen produces aneurisms and ruptures of vessels and organs than can lead to haemothorax.
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| * [[Hereditary hemorrhagic telangiectasia|Osler–Weber–Rendu disease]], also known as [[hereditary hemorrhagic telangiectasia]] (HHT), is an [[Genetic Disorders|autosomal dominant disease]] characterized by multiple [[Skin|cutaneous]], systemic, and/or [[Lung|pulmonary]] [[arteriovenous malformations]] (AVMs). Bleeding from pulmonary lesions usually occur as [[Hemoptysis|haemoptysis]] and rarely as Spontaneous Haemothorax.
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| * [[Rib|Costal]] [[exostosis]] or [[Osteochondroma]] is an [[autosomal dominant]] [[hereditary]] abnormality and the most common benign thoracic bone tumor. It often presents singly or in multiple sites that can cause laceration of the lung and hemothorax.
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| * Hemophilia A is a [[X-linked]] hereditary disorder of blood clotting that caused by the development of an inhibitor against [[Coagulation factor|coagulation factor VIII]] (FVIII). Hemophilia A manifests with early muscle and subcutaneous bleeding and rarely with haemothorax.
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| * [[Glanzmann's thrombasthenia|Glanzmann thromboastenia]] is an [[Autosomal recessive|autosomal-recessive]] bleeding disorder characterized by a lifelong bleeding tendency due to abnormalities of the platelet [[Integrin|integrin αΠbβ3]] [[[glycoprotein]] (GP) IIb; CD41/IIIa; CD61]. Glanzmann thromboastenia usually presents with [[Mucocutaneous zone|mucocutaneous]] bleeding such as [[easy bruising]], [[purpura]], [[gingival bleeding]], [[epistaxis]], [[menorrhagia]], [[Hemarthrosis|haemarthrosis]], [[Hematuria|haematuria]], [[Intracranial hemorrhage|intracranial and visceral hemorrhage]] are rare but even rarer is Spontaneous Haemothorax.
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| * [[Neurofibromatosis type I|Type I neurofibromatosis (NF-1) or Von recklinghausen disease (VRD)]] is an autosomal dominant disease. This entity can affect any organ system, and is characterized by skin tumors and abnormal cutaneous pigmentation. Pathogenetic mechanisms for vasculopathy associated with VRD are: (I) direct vascular invasion from adjacent tumors; and (II) vascular [[dysplasia]] with thickening and concomitant reduced strength of the vessel wall and [[aneurysm]] formation.
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| * there are other [[hereditary]] entities such as [[Genetic Disorders|Loeys–Dietz syndrome]], [[Genetic Disorders|familial thoracic aortic aneurysm syndrome]], or [[Genetic Disorders|Shprintzen–Goldberg syndrome]] that are predisposed to [[aortic dissection]] and haemothorax.
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| ==[[Hemothorax causes|Causes]]== | | ==[[Hemothorax causes|Causes]]== |
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| === Traumatic haemothorax ===
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| * [[Blunt force trauma|Blunt force injury]] cases such as those that occur in vehicular collisions and following falls or jumps from heights.
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| * [[Penetrating trauma|Penetrating thoracic injuries]] produced by stab or gunshot wounds.
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| === Spontaneous or non-traumatic haemothorax ===
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| Spontaneous haemothorax is a rare clinical condition in the absence of trauma or [[iatrogenic]] causes. Bilateral spontaneous haemothorax is a very rare entity and the main cause of it, is primary or metastatic pleural [[angiosarcoma]].
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| * Vascular disorders include [[aortic aneurysm]] rupture, rupture of thoracic [[aortic dissection]] - dissection is due to arterial hypertension followed by [[atherosclerosis]] -, rupture of a [[Saccular aneurysm|saccular aortic aneurysm]] and traumatic rupture of the [[pericardial]] sac during [[cardiopulmonary resuscitation]] in individuals with [[hemopericardium]], fatal spontaneous dissection of supra-aortic vessels without any evidence of aortic disease during pregnancy and early [[puerperium]], bronchial artery aneurysm rupture, aneurysmatic internal thoracic artery, intercostal vessels, internal mammary artery aneurysm, or pulmonary congenital aberrant vessels, ruptured [[Mycotic aneurysm|mycotic aneurysms]], [[Innominate artery|innominate]] truncal dissection, using neck veins for mainlining and rupture of a [[subclavian artery]] aneurysm, pulmonary [[arteriovenous malformation]]<nowiki/>s (AVMs), Fatal and non-fatal AVM-associated massive hemothorax is often linked to Osler–Weber–Rendu disease, associated with congenital heart disease such as rupture of a [[Patent ductus arteriosus (PDA)|patent ductus arteriosus]], [[Eisenmenger's syndrome|Eisenmenger syndrome]], [[aortic coarctation]] and [[bicuspid aortic valve]] disease.
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| * Malignancies causing spontaneous hemothroax include [[lymphangiosarcoma]] and vascular mediastinal [[schwannoma]], schwanommas of von Recklinghausen disease, [[lymphangioma]], [[Mediastinum|mediastinal]] [[teratoma]], [[Metastasis|metastatic]] [[choriocarcinoma]], metastatic renal carcinoma, [[Abrikossoff's tumor|Abrikossoff tumor]], pulmonary [[angiosarcoma]], [[osteochondroma]], Kaposiform endodermal sinus tumour, [[hemangioendothelioma]], hemangioma, [[hemangiopericytoma]] fibrous tumor of the pleura, [[hepatocellular carcinoma]], [[periosteal chondroma]], [[chondroblastoma]] of the rib, [[synovial sarcoma]], [[osteosarcoma]], [[Ewing's sarcoma|Ewing sarcoma]], [[neurofibrosarcoma]], [[thymoma]], mediastinal [[meningioma]], thoracic [[neuroblastoma]], pleural [[mesothelioma]], [[chronic myeloid leukaemia]], neurofibromatosis type I (Morbus von Recklinghause), [[Chondrosarcoma|chondrosarcomas]], [[ectopic]] meningioma and [[Germ cell tumor|germ cells tumors]].
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| * Connective tissue disorders: Vascular Ehlers–Danlos syndrome (Ehlers–Danlos type IV, EDS IV), [[Marfan's syndrome|Marfan syndrome]], Loeys–Dietz syndrome, familial thoracic aortic aneurysm syndrome, Shprintzen–Goldberg syndrome and Type I neurofibromatosis (NF-1) or Von recklinghausen disease (VRD).
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| * Pleural disorders: spontaneous [[pneumothorax]], Spontaneous [[pneumohemothorax]] (the accumulation of >400 mL of blood in the pleural cavity in association with spontaneous pneumothorax) and pleural metastasis.
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| * [[Exostosis|Costal exostoses]] or osteochondroma occurs either sporadically or as a manifestation of a genetic disorder known as [[hereditary multiple exostoses]] (HME). Lesions mainly occur in infants and children and their complications include haemothorax, pneumothorax, diaphragmatic or pericardial lacerations and visceral pleural injury.
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| * [[Gynaecology|Gynecological]] disorders: Intrathoracic implantation of ectopic [[Endometrium|endometrial tissue]] occurs as a result of migration of endometrial tissue through the diaphragm. Spontaneous haemothorax may be a response to cyclical hormonal changes in [[Menstrual cycle|menstruating]] women.
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| * Hematological disorders: hemophilia, [[Immune-mediated disease|immune-mediated]] platelet destruction due to Many drugs such as [[Sedative|sedatives]], [[tranquilizers]], [[Anticonvulsant|anticonvulsants]], and [[heparin]], [[anticoagulant]]-associated hemothorax, specifically, as a result of thrombembolic disease treatment, hematology-related hemothorax include Glanzmann thrombasthenia, [[thrombotic thrombocytopenic purpura]], and intrathoracic [[extramedullary hematopoiesis]], intrathoracic extramedullary hematopoiesis due to a secondary process, such as [[Myeloproliferative disease|myeloproliferative disorders]], [[hemolytic anemia]], [[hereditary spherocytosis]], chronic [[asthma]], and [[Gaucher's disease|Gaucher disease]], [[beta thalassemia]], rupture of extramedullary hematopoietic pulmonary nodules, Haemothorax has been also reported in the setting of plasminogen activator user for [[venous thrombosis]] in patient with [[pneumonia]].
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| * Miscellaneous: [[tuberculosis]], [[necrotizing]] lung infection, [[uremia]], spontaneous hemothorax secondary to a ruptured [[Hydatid cyst|parasitic hydatid (Echinococcal) cyst]] of pulmonary [[parenchyma]], [[Malaria]] is another rare parasitic etiology for spontaneous hemothorax, [[amyloidosis]]-induced spontaneous mediastinal hemorrhage with hemothorax due to perivascular and vascular wall involvement, systemic diseases like [[Systemic lupus erythematosus|systemic lupus erythematosus (SLE)]] and [[Henoch-Schönlein purpura]], [[Pulmonary embolism|pulmonary emboli]], [[ectopic pregnancy]], [[Pulmonary sequestration|Extralobar pulmonary sequestration]] (EPS), Extramedullary haematopoiesis (EMH).
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| === Iatrogenous haemothorax ===
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| Iatrogenous haemothorax may be caused by either intrathoracic vessel cannulation, chest drain insertion, needle [[thoracocentesis]], pleural or lung [[Biopsy|biopsies]], closed-chest cardiopulmonary resuscitation, placement of subclavian- or jugular-catheters, endoscopic thoracic interventions, cardiopulmonary surgery, [[sclerotherapy]] of [[oesophageal varices]], rupture of pulmonary arteries after placement of Schwann–Ganz catheters, [[Endoscopic thoracic sympathectomy|thoracic sympathectomy]] or [[Aortography|translumbar aortography]].
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| ==[[Hemothorax differential diagnosis|Differentiating Hemothorax from other Diseases]]== | | ==[[Hemothorax differential diagnosis|Differentiating Hemothorax from other Diseases]]== |
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| ==[[Hemothorax epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Hemothorax epidemiology and demographics|Epidemiology and Demographics]]== |
| The exact incidence of haemothorax is not clear. Chest injuries occur in approximately 60% of all polytrauma cases and haemothorax is most frequently caused by chest trauma. the occurrence of haemothorax related to trauma in the United States is estimated to be 300,000 cases annually.
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| ==[[Hemothorax risk factors|Risk Factors]]== | | ==[[Hemothorax risk factors|Risk Factors]]== |
| | | ==[[Hemothorax screening|Screening]]== |
| ==[[Hemothorax natural history, complications and prognosis|Natural History, Complications and Prognosis]]== | | ==[[Hemothorax natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| Bleeding into the pleural space is exposed to the motion of the [[Diaphragm (anatomy)|diaphragm]], lungs, and other intrathoracic structures. The agitation of cardiac and respiratory movement defibrinates the blood, and a [[fibrin]] [[clot]] thus formed is deposited on the layers of pleura. Within several hours of cessation of bleeding, clot formation is inevitably and it will be difficult to remove. The membrane continues to thicken by progressive deposition, so the clotted haemothorax should be evacuated within a reasonable time after onset of bleeding. Chronic and retained hemothorax may progress to develop respiratory distress, lung entrapment with impaired pulmonary function, retained clot, chronic fibrothorax, [[Pleural empyema|empyema]] and extended hospitalization if left untreated.
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| ==Diagnosis== | | ==Diagnosis== |
| The most common symptoms of hemothorax include severe chest pain, and [[dyspnea]] that can be life threatening when hemodynamic instability and [[hypovolemic shock]] occurs. Some patients with hemothorax may have reduced concentrations of hemoglobin. On chest x-ray, hemothorax is characterized by [[meniscus]] of fluid blunting the [[costophrenic angle]] or diaphragmatic surface and tracking up the pleural margins of the chest wall. Ultrasonography may be helpful in the diagnosis of hemothorax. Computed Tomographic scan is not indicated in the initial trauma setting to diagnosis of hemothorax.
| | [[Hemothorax diagnostic study of choice|Diagnostic Study of Choice]] | [[Hemothorax history and symptoms|History and Symptoms]] | [[Hemothorax physical examination|Physical Examination]] | [[Hemothorax laboratory findings|Laboratory Findings]] | [[Hemothorax electrocardiogram|Electrocardiogram]] | [[Hemothorax chest x ray|X Ray]] | [[Hemothorax echocardiography or ultrasound|Ultrasound]] | [[Hemothorax CT|CT]] | [[Hemothorax other imaging findings|Other Imaging Findings]] | [[Hemothorax other diagnostic studies|Other Diagnostic Studies]] |
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| ==Treatment== | | ==Treatment== |
| | | [[Hemothorax medical therapy|Medical Therapy]] | [[Hemothorax surgery|Surgery]] | [[Hemothorax primary prevention|Primary Prevention]] | [[Hemothorax secondary prevention|Secondary Prevention]] | [[Hemothorax cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Hemothorax future or investigational therapies|Future or Investigational Therapies]] |
| === Medical Therapy ===
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| The mainstay of medical therapy for hemothorax is, fluid resuscitation and blood transfusion. All patients, regardless of causes, require attention for fluid resuscitation and blood transfusion. prophylactic use of [[Antibiotic|antibiotics]] following haemothorax reduces the rate of infectious complications such as [[pneumonia]] and [[Pleural empyema|empyema]] during at least 24 hour after the start of chest tube drainage. Antibiotic treatment should be directed to [[Staphylococcus aureus]] and [[Streptococcus|Streptococcus species]] and the use of [[Cephalosporins|first generation cephalosporins]] during the first 24 hour in patients treated with chest tube drainage is recommended. Intrapleural [[Fibrinolytic agent|fibrinolytic]] therapy (IPFT) has been advocated as an alternative to evacuate residual blood clots and breakdown adhesions in low-resource settings where the relatively costly and sophisticated technique of VATS may not be available, feasible or applicable. Several studies report on IPFT with [[streptokinase]], [[urokinase]] or [[tissue plasminogen activator]] (TPA). Duration of treatment with IPFT can vary between 2 and 9 days for streptokinase and 2–15 days for urokinase.
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| === Surgical Therapy ===
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| The successful management of hemothorax depends on the severity of the blood loss and subsequent hemodynamic stability of the patient. The mainstay of therapy for hemothorax is intercostal chest drain (ICD) and oxygen therapy that significantly reduce the morbidity and mortality. evacuation of haemothorax by chest tube does not succeed in all cases. The resultant retained intrapleural collections are referred to as Residual Haemothorax (RH).blood in the pleural cavity may organize and fibrose, resulting in a loss of lung volume and empyema if untreated. [[Thoracic surgery|Video assisted thoracic surgery]] (VATS), minimally invasive surgery, has been found to be highly successful for treatment of these residual collections, especially when used early. VATS also can be used to treat patients with active blood loss but with stable haemodynamics, not only to stop the bleeding but also to evacuate blood clots and breakdown adhesions to prevent [[fibrothorax]] and [[Restrictive lung disease|restrictive]] physiology . An optimal period between the start of haemothorax and VATS of 48–72 h is repeatedly advocated and longer intervals lead to increased rates of complications, according to some authors. A longer time span increases the chance of intraoperative conversion to [[thoracotomy]], prolongs postoperative drainage time and is associated with a higher incidence of hospital admissions. Thoracotomy with ongoing resuscitation is the procedure of choice for patients with haemodynamic instability due to massive haemothorax or active bleeding. The criteria for thoracotomy, are blood loss by chest tube 1.500 ml in 24 h or 200 ml per hour during several successive hours and the need for repeated blood transfusions to maintain haemodynamic stability. Surgical exploration allows control of the source of bleeding and evacuation of the intrathoracic blood; and also is required for adequate empyema drainage and/or decortication.
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| === Prevention ===
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| early and adequate treatment which prevents of complication ([[suppuration]]) is necessary. some factors which most frequently promote suppuration of the thoracic cavity, developing from traumatic haemothorax. so, attention is called to secure the necessary personal and material conditions to the preventive treatment.
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| ==Case Studies== | | ==Case Studies== |