Hemothorax overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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 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.
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. Although Hunter's method was effective in evacuating the hemothorax, an iatrogenic pneumothorax as a result of the procedure was significant. Some recommended closure of chest wounds without drainage. Observing the advantages and dangers of both forms of therapy, Guthrie, in the early 1800s, proposed early evacuation of blood through an existing chest wound. Finally, by the 1870s, early hemothorax evacuation by intercostal incision was considered standard practice.
Classification
Spontaneous haemothorax (SH) is a subcategory of haemothorax.
Pathophysiology
Haemothorax is a pathologic collection of blood within the pleural cavity, between the lung surface and inner chest wall. Three mechanisms of bleeding in haemothorax include torn adhesion between the parietal and visceral pleurae, rupture of neovascularized bullae as a complication of subpleural emphysematous blebs, and torn congenital aberrant vessels branching from the cupola and distributed in and around the bulla in the apex of the lung. There are some genetic disorder that are predisposed to haemothorax.
Causes
Haemothorax may be caused by trauma or can be spontaneous and iatrogenous. Causes of traumatic haemothorax include blunt force injuries ,penetrating thoracic injuries, and thoracoabdominal injuries. Causes of spontaneous haemothorax include vascular disorders, malignancies, connective tissue disorders, gynecological disorders, hematological disorders, and miscellaneous pathological entities. Haemothorax can also be a complication of various iatrogenically-related procedures.
Differentiating [disease name] from other Diseases
- [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
- [Differential dx1]
- [Differential dx2]
- [Differential dx3]
Epidemiology and Demographics
- The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
- In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
Age
- Patients of all age groups may develop [disease name].
- [Disease name] is more commonly observed among patients aged [age range] years old.
- [Disease name] is more commonly observed among [elderly patients/young patients/children].
Gender
- [Disease name] affects men and women equally.
- [Gender 1] are more commonly affected with [disease name] than [gender 2].
- The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.
Race
- There is no racial predilection for [disease name].
- [Disease name] usually affects individuals of the [race 1] race.
- [Race 2] individuals are less likely to develop [disease name].
Risk Factors
- Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
Natural History, Complications and Prognosis
- The majority of patients with [disease name] remain asymptomatic for [duration/years].
- Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
- If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
- Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
- Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
Diagnosis
Diagnostic Criteria
- The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
- [criterion 1]
- [criterion 2]
- [criterion 3]
- [criterion 4]
Symptoms
- [Disease name] is usually asymptomatic.
- Symptoms of [disease name] may include the following:
- [symptom 1]
- [symptom 2]
- [symptom 3]
- [symptom 4]
- [symptom 5]
- [symptom 6]
Physical Examination
- Patients with [disease name] usually appear [general appearance].
- Physical examination may be remarkable for:
- [finding 1]
- [finding 2]
- [finding 3]
- [finding 4]
- [finding 5]
- [finding 6]
Laboratory Findings
- There are no specific laboratory findings associated with [disease name].
- A [positive/negative] [test name] is diagnostic of [disease name].
- An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
- Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
Imaging Findings
- There are no [imaging study] findings associated with [disease name].
- [Imaging study 1] is the imaging modality of choice for [disease name].
- On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
- [Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].
Other Diagnostic Studies
- [Disease name] may also be diagnosed using [diagnostic study name].
- Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].
Treatment
Medical Therapy
Surgery
A hemothorax is managed by removing the source of bleeding and by draining the blood already in the thoracic cavity. Blood in the cavity can be removed by inserting a drain (chest tube) in a procedure called a tube thoracostomy. Patients should recover swiftly after this. However, if the cause is rupture of the aorta in high energy trauma, the intervention by a thoracic surgeon is mandatory.
Primary Prevention
Use safety measures (such as seat belts) to avoid injury. Depending on the cause, a hemothorax may not be preventable.