Diagnosis

Hemothorax

Etiology

Cause [fvo]

1. Vascular [qd6][fnm]

   • Trauma

   • Pulmonary Arteriovenous Malformation (congenital or acquired)

   • Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome)

   • Dissection or Rupture of Aneurysms

     • Aorta

     • Pulmonary Artery

     • Splenic Artery

     • Internal Thoracic Artery

     • Internal Mammary Artery

     • Subclavian Artery

     • Ovarian Artery

     • Uterine Artery

     • Intercostal Vein

     • Venous Aneurysms

   • Ehlers-Danlos Syndrome

   • Neurofibromatosis (von Recklinghausen’s Disease)

2. Hematologic Abnormalities

   • Congenital Hemorrhagic Disorders

   • Acquired Coagulation

   • Extramedulary Hematopoiesis

   • Recombinant Plasminogen Activator

3. Neoplasia

   • Malignant Tumors

     • Mesothelioma

     • Adenocarcinoma

     • Ewing’s Sarcoma

     • Myelocytic Leukemia

     • Sarcomas

     • Angiosarcoma

     • Hepatocellular Carcinoma

     • Synovial Sarcoma

     • Choriocarcinoma

     • Schwanommas

     • Carcinoma of the Lung

     • Germ Cell Tumors

     • Primitive Neuroectodermal Tumors

     • Hemagiopericytomas

     • Costochodromas

     • Malignant Gestational Trophoblastic Disease

   • Benign Tumors and Growths

     • Benign GTDz

     • Thymic Growths and Cysts

     • Benign Thymoma

     • Venous Hemangioma

4. Complications of Pregnancy

   • Ectopic Pregnancy

   • Gestational Trophoblastic Disease

   • Peripartal Hemoperitoneum

   • Rupture of Subcapsular Hematoma

5. Thoracic Diseases

   • Rupture of Pleural Adhesions

   • Pulmonary Infarction from Thromboembolism

   • Pulmonary Infection (tuberculosis)

   • Costal Exostosis

   • Pulmonary Sequestration

6. Complications Involving the Diaphragm

   • Fenestrations

   • Endometriosis

   • Implantation of Primary Ectopic Pregnancy

7. Therapeutic Complications

   • Central venous catheter (superior vena cava, brachiocephalic veins, azygous vein)

   • Translumbar Aortography

   • Pleural Biopsy

   • Thoracentesis

   • Gastrointestinal Surgery

   • Laparoscopic Procedures

8. Idiopathic Spontaneous

Pathophysiology [qn3]

1. Hemothorax --> acute hypovolemia --> decrease in preload --> decrease in cardiac output

2. Blood in the pleural space --> reduced functional vital capacity of the lung --> alveolar hypoventilation, V/Q mismatch, and anatomic shunting

3. Hydrostatic pressure on the vena cava and pulmonary parenchyma --> reduced preload and increase pulmonary vascular resistance

4. Tension hemothorax --> hemodynamic instability, cardiovascular collapse, and death

Complications [qn3]

• Hemodynamic instability

• Shock

• Hypoxia

• Death

• Retained hemothorax:

  • Empyema

  • Fibrothorax

  • Lung entrapment

  • Impaired pulmonary function

Epidemiology

Incidence per 100.000 [8sd][fvo]

Approach

• Blood test

• Blood gas

• Chest x-ray

• FAST

• CT thorax

• Pleural fluid cytology

• Pleural fluid culture

Treatment

Specific treatment depends on the etiology [by4]

1. Conservative treatment with watchful observation if: [qn3]

   • Minimal self-limited collection of blood (<300 ml)

   • Stable patient

   • Minimal respiratory distress

2. Significant hemothorax or ongoing bleeding: >1500 ml/24hrs or 300ml/hour for 2 hrs

   • Transfusion of blood products

   • Correction of coagulopathy

   • Tube thoracostomy with evacuation of blood and clots

   • Video-Assisted Thorascoscopic Surgery (VATS)

   • Thoracotomy

Differential diagnoses

Acute respiratory distress syndrome, Cardiac tamponade, Congenital cystic adenomatoid malformation, Congenital diaphragmatic hernia, Esophageal perforation, Fracture, Henoch-Schönlein purpura, Pleural effusion, Pleural empyema, Pneumothorax, Pulmonary contusion, Pulmonary edema, Pulmonary embolism, Ruptured aortic aneurysm