Hemothorax

hemothorax for pulmonologist

1. HEMOTHORAX Dr. Chandan Kumar Sheet P. G. Student, Dept. of Pulmonary Medicine VIMSAR,Burla,Odisha,India

2. Definition - Presence of significant amount of blood in the pleural space Causes - Trauma - Penetrating Medical - Pulmonary embolism - Non penetrating - Ruptured aortic aneurism - Iatragenic - CVC in Subclavian /Jugular vein - Trans lumber aortography Source of blood - Chest wall - Lung - Mediastinum - Diaphragm Blood entering the pleural space coagulate rapidly and defibrinated due to physiologic movement of heart & lung. Loculations occur early

3. Traumatic hemothorax High incidence in blunt chest trauma Hemothorax most common with displaced rib # Concomitant occurrence of hemothorax & pneumothorax is common whether the trauma is blunt or penetrating Diagnosis – Demonstration of PLEF by CXR/USG/CT scan Treatment – Immediate ICT insertion - VATS - Arterial embolisation Occult hemothorax - hemothorax seen in CT scan but not in CXR. -Tube thoracostomy not required

4. Tube thoracostomy Indication - diaphragmatic dome is obscured or - fluid >2cm in thickness in lateral decubitus CXR Conditions indicating immediate ICT - Cardiac temponade - Continued pleural hemorrhage - Vascular injury (initial chest drain if >1500 ml ) - Pleural contamination - Debridement of devitalized tissue - Sucking chest wound - Major bronchial air leak Size of ICT - Large bore (24 to 36 F) Site - high ICS (4 th or 5 th ) at MAL as diaphragm may be elevated by trauma

5. Tube thoracostomy …cont.. Removal of ICT - as soon as they stop draining or cease to function as it can cause infection Advantages of immediate ICT - Allow complete evacuation of blood - Stops bleeding from pleural lacerations (if present) - Easy to quantitate the amount of bleeding - Decrease incidence of empyema ( blood is a good conductor of infection ) - Blood may be auto transfused - Rapid evacuation of blood decreased incidence of fibrothorax

6. VATS Indications - no precise criteria available but - If Bleeding >200 ml/ hr & no signs of slowing bleeding (bleeding is not from misplaced central line should be ensured) - Exsanguinating hemorrhage through the chest tube VATS is very effective in - Hemodynamically stable patient with persistent bleeding ( villavicencio et al ) - C ontrolling bleeding from intercostal vessels with lung lacerations

7. CT guided arterial embolisation Patient with persistent bleeding first CECT thorax is done to detect the injured vessel (exhibit contrast extravasation) then trans catheter arterial embolization done Prophylactic Antibiotics Role of prophylactic antibiotics for prevention of empyema in patient of Tube thoracostomy in hemothorax is unclear. A Study done by Maxwell et al showed that - 1.3% patient with antibiotics developed empyema - 5.6% patient receiving no antibiotics developed empyema Longer duration of ICT & high thoracic trauma score associated with higher incidence of empyema

8. Autotransfusion Barriot et al showed that pre hospital auto transfusion (in ambulance) may prevent death in life-threatening hemothorax . They developed a system containing a 28-30 F ICT with auto-transfusion device (750 ml bag with filter). The blood drains by gravity to ICT bag then re-transfused without anticoagulant into a central line. During transfer to the hospital 18 patient received 4.2 ± 0.6 L of autotransfusion 13 patient survived with out complications

9. Complications of Hemothorax Clot Retention(3%) Pleural infection (3 to 4 %) Pleural effusion (13-34%) Fibrothorax (<1%)

10. Clot Retention In spite of ICT drainage some amount of blood may retain in pleural space and leads to complications CXR - may misleading hemothorax with suspected clot retention CT scan - should be perform before surgical removal of clot If clot retention is diagnosed three question need to be asked 1)Clot removal needed or not? 2)When to remove? 3)How to remove? Indication of clot removal- If the clot occupy atleast 1/3 of involved hemithorax 48 to 72 hrs after initial ICT it should be removed

11. Clot Retention.. cont .. How to remove- - Thoracoscopy (best method 48-72 hrs. after initial injury) - VATS (optimal method) - 2 nd chest tube insertion (failure is high, eventually require thoracoscopy or thoracotomy) - Intra pleural fibrinolytics - (not recommended) - more expensive than thoracoscopy - longer hospitalization than thoracoscopy - Hypoxemic respiratory failure When to remove- between 48-72 h0urs (optimal time) Complications - Retained collection - Persistent pleural drainage - Air leaks - Empyema - Fibrothorax

12. Post traumatic empyema Prevention - strict sterile technique during ICT - Ensuring good apposition between both pleura (no space to accumulate the fluid or blood) Risk factor - Presence of BPF - Pulmonary contusion - Residual clotted haemothorax - Gross contamination of pleural space during injury - Patient with shock - Patient with associated abdominal injury - Prolonged pleural drainage Antibiotic administration reduced chance of empyema

13. Post hemothorax PLEF PLEF are common after ICT in hemothorax Wilson et al reported that - 13% patient with out any residual blood developed PLEF after ICT removal - 34 % patient with residual blood developed PLEF after discharge In This situation diagnistic thoracocentesis should be done to rule out infection. If no infection present no treatment required

14. Fibrothorax Diffuse pleural thickening producing fibrothorax irrespective of residual blood in pleural cavity Takes weeks to months after the hemothorax Occurs in <1 % of cases More common in - hemopneumothorax - pleural infection Treatment - Decortication (definitive treatment)

15. Iatragenic Hemothorax Causes- - Central venous catheterization - Injury during trans lumber aortography - Thoracocentesis - Pleural biopsy - Swan- Ganz catheterization Rare cause - percutaneous lung aspiration or biopsy - trans bronchial biopsy - sclerotherapy in esophageal varices - In ICU- common following invasive p rocedure in patient with CRF Treatment - ICT

16. Non traumatic hemothorax Cause - Malignant pleural disease (most common) - schwanomma of von recklinghausen disease - Sarcoma - angiosarcoma - HCC - Anticoagulant therapy in PE - Catamenial haemothorax - Bleeding disorder- hemophilia, thrombocytopenia - Complication of spontaneous pneumothorax - Rupture thoracic aorta, aneurismal tear, rupture pulmonary AV fistula, rupture PDA, rupture coaractation of aorta, - Intrathoracic extramedullary haematopoiesis -Chicken pox pneumonia - Bronchopulmonary sequestration -Unknown cause

17. Nontraumatic hemothorax ..cont.. Diagnosis- Pleural fluid Haematocrit - > 50% of blood Or Pleural fluid RBC > 50% of blood [ a rough estimation of haematocrit can be obtained by pleural fluid RBC/1,OO,OOO ] [ hematocrit <5 % in pleural fluid may look like blood] Treatment - ICT - thoracotomy / VATS- [If bleeding >100ml/ hr ] - Angiographic embolization [if bleeding from intercostal artery]

18. Hemothorax complicatind anticoagulant therapy Occurs mainly in treatment of pulmonary embolism Drugs responsible -heparin -warfarin -enoxaparin Hemothorax is apperent 4-7 days of initiation of treatment mainly Treatment - Discontinuation of anticoagulant - Immediate ICT

19. Catamenial Hemothorax Unusual Occurs in conjunction with menstruation Associated with endometriosis Rt hemithorax almost always involved Diaphragmatic fenestration and pleuro-peritonial communication demonstrated in some patient Most patient have pleural endometriosis Treatment - Suppression of ovulation by-OCP, progesterone - Suppression of gonadotrophin by – danazole , GnRH - Pleurodesis [if hormonal therapy fails] - THBSO

20. Spontenious Hemopneumothorax Most common cause of non traumatic hemopneumothorax Different study shows that 3.8% to 6.6 % patients of spontaneous pneumothorax have hemopneumothrax Sourse of bleeding- -Aberrant vessels - Torn parietal pleura - Torn vascular adhesion band from parietal pleura - Vascular bleb Treatment- - VATS – if bleeding >100ml/ hr or hypotension

21. THANK YOU….