continuing our review for the chest tube series and talking about the disorders that disrupt the pleural space in this lesson we're going to be quickly covering the hemothorax [Music] all right you guys welcome back to another video lesson from icu advantage my name is eddie watson and my goal is to give you guys the confidence to succeed in the icu by making these complex critical care subjects easy to understand i truly hope that i'm able to do just that and if i am i do invite you to subscribe to the channel down below when you do make sure you hit that bell icon and select all notifications so you never miss out when i release a new lesson as always the notes for this lesson as well as all the previous videos are available exclusively to the youtube and patreon members you can find links to join both of those down in the lesson description below also don't forget to head over to icuadvantage.com or follow that link down in the lesson description to take a quiz on this lesson test your knowledge while also being entered into a weekly gift card as well as don't forget that you can help support this channel through the purchase of an icu advantage sticker again those are found at the website icuadvantage.com forward slash support link down in the description so again for these lessons it is helpful to have a good understanding of the mechanics behind how it is that we breathe if you need a review on this i'm going to link to a lesson up above where i cover just that so let's start off talking about what is a hemothorax and here if we break the word down we have hemo meaning blood and thorax meaning chest so essentially this is going to be a collection of blood in the chest or more specifically the pleural space now having blood in this pleural space does a couple of different things it takes up space and puts pressure on the lung tissue keeping them from really fully expanding so this is going to cause something that we call alveolar hypoventilation lead to a vq mismatch so a ventilation perfusion mismatch and essentially anatomical shunting where we're going to be perfusing area of the lung without any good gas exchange taking place now if the hemothorax is large enough it can also put hydrostatic pressure on both the vena cava and the vessels in the lung tissue itself so this decreases preload and then also increases our pulmonary vascular resistance so sort of the afterload on the right side of our heart and can really lead to decreased cardiac output hemodynamic instability and then potentially cardiac rest and this is something that we refer to as tension hemothorax so very similar to our tension pneumothorax and then finally each hemithorax can also hold more than 1 500 mls of blood and so bleeding here can really lead to significant blood loss and then potentially ultimately hypovolemic or hemorrhagic shock so let's talk about some of the causes of this and the ways that we type or classify them so a hemothorax is caused simply by bleeding into this pleural space and so the first type that we can have is once again going to be our traumatic hemothorax and this is really going to be the most common cause that we see for this and so this can be the result of penetrating trauma where bleeding is coming from either injury to the chest wall and its structures and or damage to the lung tissue itself and its structures it can also be the result of blunt trauma and our typical culprit here is going to be rib fractures that then either damage intercostal vessels or the lung tissue itself damage to the aorta may also result and then obviously would result in a massive hemothorax and then obviously patients who are on anticoagulants are going to be of greater risk here now for our next type just like with our pneumothoracies we also have the iatrogenic causes which really are also considered types of traumatic events and then these can include things like subclavian central line insertion pa catheter rupture of the pulmonary artery lung biopsy surgery and cpr really just to name a few and then for the final type is going to be again are non-traumatic or essentially our spontaneous and really our spontaneous causes are going to be less common causes for hemothorax potential causes though that would be considered non-traumatic or spontaneous would be cancer vascular disorders including rupture of the aorta anticoagulant therapy and as well as some portion of pneumothoracies can lead to hemothorax this is something combined together that we refer to as a pneumohemothorax so let's talk about our signs and symptoms and really many of the signs and symptoms of a hemothorax are going to be the same as we see with the pneumothorax so these are going to be our chest pain shortness of breath that dyspnea or tachypnea decreased or absent breath sounds hypoxemia and hypercapnia now some different signs and symptoms that are going to be a little bit more specific to the hemothorax versus the pneumothorax would be tachycardia and this is again going to be a result of the compensation from blood loss but isn't necessarily indicative of attention because we can have this tachycardia just from the blood loss alone for these patients we're also going to have a dullness to percussion because now we're starting to fill up with fluid here we can see a little bit more chest wall asymmetry or excessive abdominal breathing and this could be the result of a flail chest injury and then in those cases of the tension hemothorax again the signs and symptoms are going to be similar to the tension pneumothorax as they're really the result of that cardiopulmonary compromise so again that tachycardia jvd may or may not be present really kind of depending on the extent of the hypovolemia that the patient's experiencing from that blood loss again they can have that same tracheal deviation away from the affected side cyanosis can be present that profound hypoxemia and hypotension as well as the respiratory failure and potentially cardiac arrest all right so let's talk about the diagnosis of the hemothorax so just like with the pneumothoracies the signs and symptoms here are going to be vague and imaging is really going to be needed so the first of these that we're going to talk about is going to be the chest x-ray and once again we have our posterior interior or our pa chest x-ray which is going to be commonly used to diagnose a hemothorax and so here's an example here of actually a pretty pretty sizable chemothorax in the patient's left lung and so what we're really looking for is we're going to be seeing blunting of the costophorenic angle which is going to be down here at the base of the lung the lateral side as well as the opacification of the affected hemothorax and so in this example here it's pretty obvious because it's a pretty large hemothorax so you can see this hole opacification here this is going to be the blood and then the rest of this here is going to be our lung tissue now one thing to kind of keep an eye on is patients who are supine or lying down that the blood can actually kind of layer in the pleural space not having necessarily a collection like we're seeing in that example there and this can actually lead to haziness of one half of the hemothorax when we really compare it to the other so here's an example of this here and you can see at that costophoretic angle that we do have that blunting so it's not the sharp edge like we see over here on this side but then when you just look at the lung itself it's kind of a little bit more gray a little bit more opacified but we don't see necessarily that large collection like we did on the previous example now one important thing to know is that with the chest x-ray we're not going to be able to distinguish between if this is a hemothorax or some other pleural effusion obviously our history of what's going on with the patient is really going to kind of play into that so clearly if they're a trauma patient we can pretty much assume that this is going to be a hemothorax all right the next bit of imaging is going to be our computed tomography or our ct scan and so here the ct is going to really give us the best look at the location and the size of the hemothorax along with any other potential injury to other structures as well as potential sources of bleeding and so here is another example this time of a ct scan and here it's pretty obvious again where we have our hemothorax or our collection of fluid or blood and then we have the rest of the lung tissue around here as opposed to over on the other side you can see it's pretty clearly all just lung tissue now again the ct is not used routinely as our primary diagnosis but we will often use it especially for trauma patients once that trauma is stabilized and this is really important because sometimes smaller dependent hemothoracies can actually be hidden on x-ray behind the diaphragm and some of the abdominal structures and then again in cases of like unstable traumas or emergencies it just might not be possible to transport the patient for a ct scan and so that brings us to our next form of imaging for diagnosis and that's going to be our ultrasound so really the use of the bedside ultrasound is growing in its use and really its support and evidence for really rapidly being able to evaluate the presence of bleeding in fact the ultrasound is more sensitive than the x-ray at detecting really small hemothoracies as small as 20 mls of blood whereas an x-ray generally need about 150 or more to kind of see it on there and so as a result it's actually considered a superior diagnostic tool so here's just a quick example and so here this is going to be pretty obvious we've got the the black section here which is going to be the blood and that's resting on top of our diaphragm over here on the right and then we've got our lung tissue over here on the left there are also some other diagnostic indicators but i just really wanted to kind of show you guys this as an example and so in trauma it's pretty often that we are going to be utilizing the ultrasound sometimes even potentially before an x-ray and it's something that's also being adopted in a lot of places in different dyspnea protocols as well so for the trauma we typically have something that we call the focused assessment with sonography and trauma or the fast scan and this is taking a quick look with the ultrasound probe and really looking at four primary areas the pericardium the paraspleenic the para hepatic and the pelvis and really they're just looking to see if there's bleeding in any of those compartments as these would be very emergent urgent situations that would either need rushing to the or or potentially intervention there on the table now there is something that we refer to as the expanded e-fast which includes in addition to looking at those four areas both oblique and anterior evaluations of the hemothorax really looking for the dependent fluid and as well as pneumothorax as well and with that ultrasound we're able to get that assessment in pretty quickly and really kind of see if the patient has any bleeding or has any air in that pleural space all right so now let's talk about the treatment for hemothorax and our treatment options really are going to depend on the size of the hemothorax the cause and the symptoms so once again starting out we do have our conservative treatment and then here for our hemothoracies that are smaller than 300 mls we really may elect to do nothing and just kind of monitor the patient and again these are going to be patients that are asymptomatic as well and so the blood is usually going to be absorbed by the body over a few weeks and thus may require very little in the way of treatment for these patients typically we're just going to treat them with analgesics as needed keep an eye on their labs and then do some follow-up imaging as well another potential treatment option is a thoracentesis although this is not something that is commonly going to be used but it is potentially an option for some hemothoracies so next is going to be our chest tube and again the gold standard for treatment of a hemothorax is going to be our chest tube so the chest tube is going to allow us to do a couple things obviously it's going to allow us to drain the hemothorax we're going to be able to record that drainage and then more importantly sometimes is we're going to be able to monitor that drainage for continued bleeding now for our chest tubes for hemothorax we're generally going to be a little bit lower than we were for a pneumothorax so typically we're going to try to insert it at the fifth intercostal space mid axillary line and again this kind of keeps it in that safe region away from any additional organs and then when we do insert it we're going to be going posterior on the lung and potentially towards the base along as well to try to aid with that drainage now we can also potentially do a chest tube for a hemothorax and insert it at either the sixth or the seventh intercostal space and this potentially would give us some better drainage but it does have the increased risk for organ damage as well as entering into the abdomen and then for these we're typically going to start the suction off at negative 20 centimeters of water and then four are hemothoracies we're typically going to use larger chest tubes and these are typically in the range of 32 up to 40 french and the purpose of using these larger chest tubes is to allow for proper drainage while also not clotting off that said there are some studies that have actually shown no negative impact to outcomes when we use 28 to 32 french for our chest tube size in the case of traumas when we compare it to the largers now one of the reasons our placement is kind of important is because if we end up having a hemothorax that clots and it's not really evacuated well then we're at risk for a couple complications so the patient can potentially develop an infection and a collection of plus something that we will refer to as an empyema and then also having improper drainage can also lead to pleural inflammation and really kind of preventing proper lung expansion and then the clotted blood that's in there can attach the pleura to one another leading to scarring something that we call fibrothorax and so if we do end up with a hemothorax that is clotted we can either treat that with intrapleural hemolytic therapy or potentially surgery and so here a hemolytic agent can be infused through the chest tube into the intrapleural space in an attempt to kind of break up that clot that's in there now another thing for treatment when it comes to our hemothorax is actually going to be our blood and volume replacement so in cases of the larger hemothoracies we're potentially going to need to also treat our patients hypovolemia so in these cases obviously blood is going to be our preferred replacement but fluids can also be used initially until that blood becomes available now another treatment option is actually going to be embolization and so here for our larger bleeds that are coming from arterial sources one option is for the patient to actually go to ir and have a transcatheter arterial embolization done with the goal of stopping any ongoing bleeding that's taking place and then finally the last treatment option i want to talk about is going to be surgery and so in a decent number of traumatic chemothoracies surgery is often going to be required and so here again this can either be an open thoracotomy or a video assisted or a vat so if we have a patient that has a large volume bleed so more than 1500 mls in 24 hours or if they're having three to five hundred mls an hour for two to four hours post chest tube placement if we're having to give them repeated blood transfusions if they have any sort of hemodynamic instability great vessel and chest wall injuries potentially then doing a thoracotomy is going to allow better assessment of the particular injury as well as the bleed and better manipulation and control of that bleeding obviously during that time we would evacuate the blood that's in there and then have a chest tube placed for post surgery and then again for the cases where we do have the clotted hemothoracies surgery may be necessary for the evacuation of that clot as well as potentially a decortication of the empiema all right and that was our review of our hemothoracies again i really hope that you guys found this information useful a lot of good information in here talking about what they are how our patients come across them how do we diagnose and really kind of see them on different imaging some of those signs and symptoms that you're looking for and then ultimately what are our different treatment options available again it's good to kind of have a good understanding of this information because you never know when you're going to come across this and what you might be expecting in terms of what your patient might be going through and what they potentially have planned as far as our options for them so i hope that you guys found this information useful if you did please leave me a like on the video down below it really helps youtube know to show this video to other people out there as well as leave me a comment down below i love reading the comments that you guys leave and i try to respond to as many people as i can make sure you subscribe to this channel if you haven't already and a special shout out to the awesome youtube and patreon members out there the support that you're willing to show me and this channel is truly appreciated so thank you guys so very much if you'd be interested in showing additional support for this channel you can find links to both the youtube and patreon membership down below head on over there and check out some of the perks that you guys get for doing just that as well as check out some of the links to 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