Spontaneous hemothorax in hemophilia: case report and discussion of the hemophilia syndromes, with remarks on the management of hemothorax.
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Disease Management↗
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[Hemothorax with special reference to acute idiopathic hemothorax].
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Hemothorax↗
Hemothorax as a presenting symptom in abdominal pregnancy: markedly elevated chorionic gonadotropin titer findings associated with abdominal pregnancy and secondary hemothorax.
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Chorionic Gonadotropin↗
[Treatment with intrapleural streptokinase for coagulated hemothorax after cardiac surgery with cardiopulmonary bypass].
INTRODUCTION AND OBJECTIVES: Coagulated hemothorax is a complication of cardiac surgery with cardiopulmonary bypass. The objective of this study was to present the authors' experience in the intrapleural infusion of streptokinase for the treatment of this complication. METHODS: From January 1996 to June 1999, nine patients (6 males, 3 females, age range: 1-75 years) were clinically and radiographically diagnosed with coagulated hemothorax after cardiac surgery. All patients were treated with intrapleural infusion of streptokinase at a standard dose of 250,000 units in adult patients and 12,000 U/kg in pediatric cases. In cases of occluded chest drainage, the position of the patient was changed and drainage was opened. RESULTS: In all the cases clinical and radiological improvement was observed and 100 to 200 ml of hemothorax was obtained on drainage. One patient died of multiorgan failure due to the underlying disease not related to the procedure. No alteration were observed in hematological tests including coagulation. The other 8 patients were discharged from hospital and remain without pulmonary compromise to date. CONCLUSION: Treatment of coagulated hemothorax with intrapleural infusion of streptokinase is a useful procedure and avoid the need for surgical drainage of hemothorax.
Adult↗
Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity.
OBJECTIVE: To describe the nature of delayed hemothorax occurring after blunt thoracic trauma and to identify the population at risk for this complication. METHODS: A retrospective review was conducted of 36 consecutive patients with hemothorax consequent to blunt trauma. Criteria for the definition of delayed hemothorax were established involving normal interval chest radiographs or computed tomographic scans during hospitalization. RESULTS: Twelve cases of delayed development of hemothorax were identified. Ninety-two percent of cases occurred in patients with multiple or displaced rib fractures. Presentation occurred from 18 hours to 6 days after injury. Eleven of the 12 cases were heralded by a prodrome of new pleuritic chest pain and dyspnea that occurred from 4 to 19 hours before treatment. CONCLUSION: Delayed hemothorax after blunt trauma is a unique entity occurring in patients with multiple or displaced rib fractures. Vigilance for the recognizable prodrome in the high-risk population should allow early remediation of this complication.
Aged↗
Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient.
BACKGROUND: The early removal of large residual posttraumatic hemothorax by videothoracoscopy is increasingly used to avoid the late sequelae of trapped lung and empyema. Plain chest radiography (CXR) is the tool most frequently used to select such cases for operation. Our recent experience has demonstrated that what appears to be a large retained hemothorax on CXR may turn out to be intrapulmonary or extrapleural conditions not amenable to thoracoscopic removal. Our objective was to evaluate the accuracy of CXR in detecting significant residual hemothorax and compare its clinical value to thoracic computed tomography (CT) when used to select patients for thoracoscopic evacuation. METHODS: All patients requiring tube thoracostomy for traumatic hemothorax were prospectively evaluated during a 22-month period (n = 703). Patients who, on the second day after admission, demonstrated opacification on CXR involving more than the costophrenic angle were evaluated by thoracic computed tomography for the presence of undrained fluid. Second-day CXR (CXR2) results were compared with the CT findings. Incorrect interpretation was defined as a difference of more than 300 mL between the two readings. All CXR2 and CT results were reviewed in the same fashion by a radiologist blinded to the surgeon's interpretations. Data on injury mechanism, hemodynamic status, laboratory values, interventions, and outcome were collected prospectively. RESULTS: Fifty-eight patients had clinically significant opacifications on CXR2. The surgeon's and radiologist's CXR2 interpretations were incorrect in 48 and 47% of the cases, respectively. The CT interpretations by the two specialists were in agreement in 97% of the cases. Management that would have been instituted on the basis of CXR2 findings was changed in 18 cases (31%). Twelve patients (21%) required early thoracoscopic evacuation of undrained collections. There was good correlation between the CT estimation and the thoracoscopically retrieved amount of blood. CONCLUSION: Although CXR is useful as a screening tool, it cannot be used to reliably select patients for surgical evacuation of retained traumatic hemothorax. Decision-making should be based on thoracic CT findings.
Adult↗
Hemothorax in 2 horses.
This report documents the successful conservative medical management of hemothorax in 2 horses. Hemothorax occurred after a lung biopsy procedure (horse 1) and strenuous exercise on a treadmill (horse 2). The horses had tachypnea, tachycardia, nostril flaring, hemoptysis, and pawing. Hemothorax was suspected based upon absence of auscultable ventral lung sounds; development of cool extremities and pale, tacky mucous membranes; the ultrasonographic appearance of moderate to severe amounts of pleural fluid; and a concurrent decrease in hematocrit and total plasma protein. Both horses were treated successfully by intranasal administration of oxygen, intravenous administration of balanced polyionic solutions, and treatment with antibiotics, nonsteroidal anti-inflammatory drugs, and analgesics. In neither case was pleural blood removed. The hemothorax resolved in both horses without lasting abnormalities. Hemothorax does not require drainage for successful resolution.
Analgesics↗
Reevaluation of early evacuation of clotted hemothorax.
During an 181/2 year period, we encountered 14,300 patients with blunt or penetrating thoracic or thoracicoabdominal trauma. In 155 patients, residual clotted hemothorax or empyema developed later. Thirty-nine patients underwent early evacuation of clotted hemothorax with no mortality and an average hospital stay of only 10 days. When progression to empyema occurred, the mortality rate increased to 9.4 percent and the average hospital stay to 37.9 days. The most common related event in the development of empyema was concurrent injury to intraabdominal organs and the inevitable bacterial contamination of the thorax. In a small number of patients, tube thoracostomy drainage is inadequate and results in residual clotted hemothorax. Despite recent pleas for conservative, expectant management, it is our experience that early evacuation of clotted hemothorax is not only cost-effective, it is also associated with lower morbidity, lower mortality, and reduces the chance of development of empyema.
Abdominal Injuries↗
[A rare complication of multiple exostoses: hemothorax].
BACKGROUND: Hemothorax is a rare complication of hereditary multiple exostosis. CASE REPORT: A 12 year-old boy suffered from abrupt thoracic pain, firstly attributed to pleural effusion. He had hereditary multiple exostosis known since the age of 9 years. The patients was given anti-inflammatory drugs and erythromycin but the pleural effusion became more abundant 6 days later requiring thoracentesis which showed hemothorax. All bacteriological and cytologic investigations were negative. X rays, ultra-sonography and CT scan showed several costal exostoses developing into the thoracic cavity. The hemothorax disappeared within 12 days and the patient was well 4 months later, without pleural sequelae. CONCLUSIONS: Hemothorax may be due to internal costal exostosis. It may be cured with thoracentesis; more aggressive therapy should be performed in exceptional cases with severe and/or recurrent bleeding.
Child↗
Trauma ultrasound examination versus chest radiography in the detection of hemothorax.
STUDY OBJECTIVE: To compare the sensitivity, specificity, and accuracy of ultrasonography with those of the initial plain chest radiograph for detection of hemothorax in trauma patients. METHODS: Data from a prior prospective study of trauma ultrasonography at a Level I trauma center were retrospectively analyzed. The medical records of a convenience sample of adult patients who presented with major blunt or penetrating torso trauma during a 17-month period were reviewed. Emergency physicians performed a trauma ultrasound examination, which included evaluation for pleural fluid. Ultrasound interpretations were recorded before other diagnostic tests were obtained and were not used in patient management decisions. Records of the study patients were reviewed for confirmation of the presence or absence of hemothorax by other diagnostic and therapeutic interventions. The chest radiograph and computed tomography (CT) scan interpretations were performed by attending radiologists who were not blinded to patient outcome. RESULTS: Five of the 245 patients enrolled in the study were excluded because tube thoracostomy was performed before the ultrasound examination was done. Altogether, 26 of the 240 study patients had hemothorax, as confirmed by tube thoracostomy or CT. Both ultrasound examination and the initial chest radiograph resulted in 0 false-positive, 1 false-negative, 25 true-positive, and 214 true-negative findings. Overall, both modailties were 96.2% sensitive, 100% specific, and 99.6% accurate. CONCLUSION: Ultrasonography is comparable to the initial chest radiograph for accuracy in detection of hemothorax and may expedite the diagnosis and treatment of this condition for patients with major trauma.
Adult↗
Emergency department ultrasound for hemothorax after blunt traumatic injury.
Diagnosing hemothorax after blunt trauma may be aided by emergency department (ED) ultrasound (US). Various prior studies have evaluated ED US using different gold standards. A prospective study of blunt trauma patients who underwent computed tomography (CT) scan of the chest, abdomen, or both, was performed. Before CT scan, an US examination was performed specifically to identify free fluid in the thorax. The CT scan findings were used as the gold standard for validation of US results. From July 1998 to June 1999, 142 of 155 patients who underwent US and CT scan for evaluation of blunt trauma were included in this study. The CT scan identified 16 cases of hemothorax among these patients. ED US resulted in 2 true-positive, 2 false-positive, 14 false-negative, and 124 true-negative findings. ED US was 12.5% sensitive and 98.4% specific. ED US did not detect small-volume hemothorax identified by CT scan. Future research should focus on further defining the size of hemothorax appreciable with ED US, with increased attention paid to the type of gold standard implemented for its evaluation.
Cohort Studies↗
Follow-up chest radiographs after traumatic pneumothorax or hemothorax in the outpatient setting: a retrospective review.
PURPOSE: To evaluate the need for obtaining postdischarge chest radiographs for trauma patients who were treated with a thoracostomy tube. METHODS: A retrospective medical record review was conducted for all patients treated with a thoracostomy tube while admitted to the trauma service at Saint Louis University Hospital over a 12-month period. Patients who died during their hospital stay were excluded. RESULTS: During the 12-month study period, 155 trauma patients who were treated with a thoracostomy tube were discharged from the hospital. The indications for the thoracostomy tube were pneumothorax (n = 79, 51% of study population), hemopneumothorax (n = 34, 22%), hemothorax (n = 28, 18%), diaphragmatic rupture/laceration (n = 8, 5%), post thoracotomy (n = 4, 3%), and iatrogenic pneumothorax (n = 2, 1%). A follow-up clinic visit was scheduled for 1 to 2 weeks after discharge. Forty patients (26%) were lost to follow-up. Two patients called to report they had no symptoms and canceled their appointments. A total of 113 patients returned for follow-up appointments. Fifty-two patients had a predischarge chest radiograph that was negative for pneumothorax or hemothorax, had no symptoms, had normal results of a physical examination at the time of their clinic visit, and did not have a postdischarge chest radiograph. A total of 61 (54%) had postdischarge chest radiographs. Of that number, 56 (92%) were negative for pneumothorax. Three patients (5%) had a small pneumothorax, and 2 patients (3%) were noted to have a resolving hemothorax. All 5 patients were without symptoms and were released from the trauma service. CONCLUSION: A postdischarge chest radiograph is not indicated for an asymptomatic trauma patient who was treated with a tube thoracostomy and had a predischarge chest radiograph that was negative for pneumothorax or hemothorax.
Adolescent↗
Massive hemothorax complicating heparin anticoagulation for pulmonary embolus.
A case of massive hemothorax complicating heparin anticoagulation for pulmonary thromboembolism is presented. Hemothorax complicating anticoagulant therapy for PTE usually occurs within the first week of treatment and is invariably on the side of the initial clinical symptoms, suggesting intrapleural rupture of a hemorrhagic pulmonary infarct. Late hemothorax is unusual and may not be on the side of the initial symptoms, suggesting a different pathogenesis. Hemothorax may occur as the only bleeding complication of anticoagulation and when coagulation studies are within an acceptable therapeutic range. Cessation of anticoagulation therapy and prompt evacuation of the pleural space are recommended.
Hemothorax↗
Hemothorax and chylothorax.
Hemothorax and chylothorax remain perplexing medical problems. The primary cause of hemothorax is trauma, whereas the primary cause of chylothorax is cancer. Most patients with hemothorax can be treated with chest tube drainage only. Early thoracotomy with thoracic duct ligation is recommended for patients with chylothorax when conservative treatment with chest tube drainage and hyperalimentation fails. Radiation therapy is the mainstay of treatment for chylothorax related to cancer. Video-assisted thoracoscopy may play an increasing role in the surgical treatment of both hemothorax and chylothorax.
Chest Tubes↗
Bilateral and unilateral spontaneous massive hemothorax as a presenting manifestation of rare tumors.
Spontaneous true hemothorax is quite a rare manifestation of a presenting disease. This is a report of two patients, one with bilateral spontaneous massive hemothorax as a presenting manifestation of angiosarcoma involving the lungs and pleura, and the other with unilateral spontaneous hemothorax and hemorrhagic shock as a presenting manifestation of 'cystic' chondroblastoma. Differential diagnosis of spontaneous true hemothorax and its evaluation and management are discussed.
Adult↗
Intrapleural fibrinolytic treatment of traumatic clotted hemothorax.
STUDY OBJECTIVE: To evaluate the role of intrapleural fibrinolytic treatment (IPFT) in traumatic clotted hemothorax. DESIGN AND PATIENTS: Between August 1995 and February 1997, 24 patients with traumatic clotted hemothorax were included. Streptokinase (SK), 250,000 IU, or urokinase (UK), 100,000 IU, diluted in 100 mL of saline solution was given daily. We administered 5.0+/-1.8 (range, 2 to 9) doses of SK or 6.25+/-5.97 (range, 2 to 15) doses of UK. SETTING: Dicle University School of Medicine, Thoracic and Cardiovascular Surgery Department. RESULTS: Complete response, which was defined as resolution of symptoms with complete drainage of fluid and no residual space radiographically, occurred in 15 (62.5%) patients. Partial response, which was defined as resolution of symptoms with a small pleural cavity, occurred in seven (29.2%) patients. Two patients (8.3%) required decortication; they were defined as nonresponders. The mean period of time between the diagnosis and fibrinolytic treatment (FT) was 11.65+/-6.38 (range, 4 to 25) days. There were no complications related to IPFT. There was no mortality during the course of IPFT. CONCLUSION: The use of intrapleural fibrinolytic agents has resulted in resolution of clotted hemothorax with an overall success rate of 91.7%. We recommend that IPFT should be added to the algorithm for management of clotted hemothorax before proceeding with minithoracotomy or pleural decortication.
Adolescent↗
Videothoracoscopy for evaluation and treatment of hemothorax.
BACKGROUND: Hemothorax may be immediately life-threatening or lead to complications like empyema and fibrothorax. The first step of management is the placement of a tube thoracostomy which is efficacious in more than 80% of cases. Continuous bleeding and retained blood, instead, require surgical treatment. METHODS: From 1993 to 2000, 33 patients underwent videothoracoscopic treatment of hemothorax. It was post-surgical in 19 cases, spontaneous in 8 and post-traumatic in 6. Fifteen patients had a continuous bleeding (>1500 mL/24 hrs) and 18 patients a retained hemothorax (= or >500 mL). To better assess smaller retained collection 11 patients underwent both CT scans and trans-thoracic ultrasonography. Twenty-six patients (group 1) were operated within 7 days of the diagnosis and 7 after 10 days (group 2). Standard videothoracoscopic equipment was utilised with the patient under general anaesthesia and double lumen selective intubation. Two or three incisions were performed in axillary triangle (in the postsurgical ones we always utilised the existing incisions). Hemostasis was always achieved by clip ligation and electrocautery. Clotted blood underwent fragmentation and suction with a complete evacuation followed by pleural washing with antibiotics solution. RESULTS: Videothoracoscopy was effective in 32 cases. One patient of group 2 required conversion to open thoracotomy due to the presence of sticky pleural adhesions. Operating time, mean drainage period and mean hospital stay were sensitively shorter in patients of group 1 with respect to patients of group 2. At a mean follow-up of 39 months no relapses or complications were observed. CONCLUSIONS: Videothoracoscopy seems to be safe and effective in the treatment of hemothorax. To avoid prolonged operations, conversions to thoracotomy and complications, it should be performed as soon as possible. Actually only massive hemorrhages justify the thoracotomic approach.
Adolescent↗
Delayed hemothorax after blunt trauma without rib fractures.
Delayed hemothorax after blunt trauma is a rare, significantly morbid entity described in the current literature associated with displaced rib fractures. This report describes a case of delayed hemothorax after blunt trauma without rib fracture. The patient presented to a routine clinic appointment 72 hours after injuring himself while snowboarding. Chest radiographs at initial visit were negative for significant pathology. Eight hours later, the patient presented again with worsening chest pain and dyspnea. Repeat radiographs revealed a large right-sided hemothorax. The patient was treated with tube thoracostomy and remained an inpatient for 6 days. This case is unique because, unlike previously reported delayed hemothorax after blunt trauma, this patient had no evidence of rib fractures.
Adult↗