massive hemothorax

there is the introduction part of the torso trauma,
check out my next ppts for further more about torso trauma.
contents are in following order...
introduction
mechanism of injury
junctional zones of torso
tension pneumothorax
cardiac temponade
massive hemothorax
etc.
check out all slides

1. MASSIVE HEMOTHORAX NAME - DEEPIKA KOMA DEPARTMENT OF SURGERY ROLL NO. - 28 LBRK GMC JAGDALPUR BATCH - 2018 MBBS FINAL YEAR PART ll

2. CONTENTS INTRODUCTION ETIOLOGY AND RISK FACTORS PATHOGENESIS CLINICAL FEATURES EPIDEMIOLOGY SYMPTOMS SIGN COMPLICATIONS PROGNOSIS MANAGEMENT ICT IMAGING STUDIES TREATMENT BIBLIOGRAPHY

3. INTRODUCTION Rapid accumulation of greater than 1500 ml or 1/3rd blood volume in Pleural cavity. A massive hemothorax is defined as blood drainage ≥1500 ml after closed thoracostomy and continuous bleeding at 200 ml/ hour for at least 3 to 4 hours.

4. ETIOLOGY AND RISK FACTORS Traumatic hemothorax Iatrogenic hemothorax Spontaneous/disease complication hemothorax

5. Traumatic hemothorax (Usually from blunt trauma or penetrating trauma resulting in vascular injuries to): Chest wall and associated structures, Blood vessels, and Lung (rare)

6. In blunt injury Continuing bleeding from torn intercostal vessels or Occasionally from the internal mammary artery and, Secondary to fractures of the ribs CHEST WALL AND ASSOCIATED STRUCTURES

7. In penetrating injury A variety of viscera, both thoracic and abdominal (with blood leaking through a hole in the diaphragm from the positive pressure abdomen into the negative pressure thorax) may be involved.

8. BLOOD VESSELS Aorta and brachiocephalic Arteries SVC, IVC, brachiocephalic veins Pulmonary arteries and veins LUNG Lung parenchymal injury low pulmonary arterial pressure + compressing effect of blood in pleural space limit bleeding

9. 2. Iatrogenic hemothorax Central venous catheterization or thoracostomy tube placement 3. Spontaneous/disease complications Tuberculosis, pulmonary embolism, Coagulopathy, neoplasia, thoracic aortic dissection or aneurysm LESS COMMON ETIOLOGIES

10. Trauma to the thoracic cavity leads to bleeding and subsequent blood pooling in the pleural cavity PATHOGENESIS interferes with normal movement of the lungs by preventing normal expansion of the lungs

11. Mainly altered cardiac and respiratory functions Influenced by amount and rate of blood loss Large clots in pleural space release fibrinolysins leading to further bleeding Residual hemothorax increases osmotic pressure Leads to fluid transudation and increases pleural fluid volume Cont…

12. Each hemithorax can hold 40-50% of circulating blood volume Blood can accumulate rapidly in pleural space Decreases preload Compromises LV function and cardiac output LIFE-THREATENING BY 3 MECHANISMS Compresses venacava Decreases preload Compresses lung parenchyma Increases vascular resistance From lung collapse alveolar hypoventilation ACUTE HYPOVOLEMIA HYPOXIA PRESSURE OF HEMOTHORAX

13. Motor vehicle collisions (MVCs) represents the most common cause of major thoracic injuries. Hemothorax related to trauma around 300,000 cases/year 60-70% in blunt chest trauma 50-60% in penetrating trauma Incidence of hemothorax and pneumothorax increases with number of ribs fracture EPIDEMIOLOGY INCIDENCE/PREVALENCE

14. Rapid, shallow breathing Dypnea Pleuritic Chest pain Low blood pressure (hypovolaemic shock) Pale, cool and clammy skin Rapid heart rate Restlessness Anxiety SYMPTOMS

15. INSPECTION : asymmetrical Chest movement with respiration (at the affected side) , flat neck veins PALPATION : Tenderness, trachea might be shifted (if massive bleeding causes mediastinal shift) PERCUSSION : dullness at the Affected side AUSCULTATION : decreased or absent breath sound SIGNS

16. Signs and symptoms of massive hemothorax

17. DO NOT DELAY treatment for imaging study.

18. Management of massive hemothorax Volume Replacement Chest decompression Correcting the hypovolaemic shock Insertion of an intercostal drain

19. INTERCOSTAL CHEST TUBE INSERTION(ICT) Indication : Pneumothorax, hemothorax, pleural effusion Size of ICT - Large bore 24 - 36 F SITE - ICS 4th or 5th at mid axillary line Triangle of safety

20. TUBE THORACOSTOMY

21. CHEST X RAY (bedside) Portable supine May show only general haziness or opacification of affected lung field, even with 1 L of blood in hemithorax Look for rib fractures May see tracheal deviation Upright (best for primary imaging) Blunting of costophrenic angle equate to 400-500 mL of blood Air-fluid interface seen if hemopneumothorax.

22. CHEST X RAY FINDINGS

23. Ultrasound (bedside) Use as part of FAST and as adjunct with CXR Shows fluid between chest wall and lung for hemothorax With penetrating trauma, provides info on pericardial involvement Greater sensitivity and equal specificity than CXR

24. CT SCAN Use if CXR ambiguous or initial treatment fails Highest sensitivity and specificity for hemothorax More sensitive for localization of clots, loculated collections

25. TREATMENT

26. COMPLICATIONS Clot retention (3%) Pleural infection (3-4%) Pleural effusion(13-34%) Empyema(5%) Fibrothorax(1%) Complications of tube thoracostomy (25 - 30% overall complications) Improper tube placement Pneumothorax Re-expansion pulmonary edema Spleen or liver puncture Infection

27. PROGNOSIS Mortality/Morbidity Thoracic injuries responsible for 20-25% of all trauma-related deaths 15% of those with chest trauma need thoracotomy Risk factors for mortality among blunt trauma patients Age > 64 years old > 2 rib fractures Pre-existing disease, especially cardiopulmonary.

28. DIFFERENTIAL DIAGNOSIS Pneumothorax Tension pneumothorax Cardiac temponade Pulmonary laceration Tracheal / Bronchial injuries Non-aortic vascular trauma Traumatic aortic rupture Penetrating cardiac injuries

29. BIBLIOGRAPHY Bailey and love’s short practice of surgery SRB’s mannual of surgery

30. Thank you