Hemothorax

Introduction

• Presented by ICU Advantage (Eddie Watson)
• Aim: Simplify critical care subjects for ICU success
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Basics of Hemothorax

• Definition: Collection of blood in the chest (pleural space)
• Effects on Lungs:
  • Takes up space and puts pressure on lung tissue
  • Causes alveolar hypoventilation
  • Leads to VQ mismatch (ventilation-perfusion mismatch)
  • Potential for anatomical shunting
  • Can cause decreased cardiac output and hemodynamic instability
  • Severe cases can lead to tension hemothorax

Capacity and Impact

• Each hemithorax can hold >1500 mL of blood
• Significant blood loss leads to hypovolemic or hemorrhagic shock

Causes and Classification

• Traumatic Hemothorax:
  • Penetrating trauma or blunt trauma
  • Rib fractures, damage to lung tissue or aorta
  • Increased risk in patients on anticoagulants
• Iatrogenic Causes:
  • Subclavian central line insertion, PA catheter, lung biopsy, surgery, CPR
• Non-traumatic (Spontaneous) Hemothorax:
  • Cancer, vascular disorders, anticoagulant therapy
  • Pneumohemothorax (combination of pneumothorax and hemothorax)

Signs and Symptoms

• Common with Pneumothorax:
  • Chest pain, shortness of breath, dyspnea, tachypnea
  • Decreased or absent breath sounds, hypoxemia, hypercapnia
• Specific to Hemothorax:
  • Tachycardia, dullness to percussion
  • Chest wall asymmetry, excessive abdominal breathing
  • Tension Hemothorax: Tachycardia, JVD, tracheal deviation, cyanosis, hypotension, respiratory failure, cardiac arrest

Diagnosis

• Imaging:
  • Chest X-ray: Blunting of costophorenic angle, opacification of hemithorax
  • CT Scan: Detailed look at location, size, and other injury
  • Ultrasound: Rapid evaluation, more sensitive than X-ray for small bleeds
  • FAST Scan: Used in trauma to assess bleeding in pericardium, spleen, liver, and pelvis
• Limitations: Chest X-ray cannot differentiate between hemothorax and other pleural effusions

Treatment

• Conservative Treatment:
  • For hemothoraces <300 mL, asymptomatic patients
  • Monitoring, analgesics, follow-up imaging
• Thoracentesis: Rarely used
• Chest Tube: Gold standard, placed at 5th intercostal space, mid-axillary line, larger tube (32-40 French)
• Blood and Volume Replacement: For hypovolemia, blood preferred but fluids can be used
• Embolization: For arterial bleeds
• Surgery: Necessary for large bleeds, continued bleeding, hemodynamic instability
  • Thoracotomy or VATS
  • Evacuation of hemothorax, chest tube placement post-surgery

Complications

• Potential for infection (empyema)
• Pleural inflammation, improper lung expansion
• Clotted blood leading to pleural adhesion (fibrothorax)

Conclusion

• Importance of understanding hemothorax for ICU care
• Diagnostic and treatment options to manage patients effectively
• Encouragement to subscribe and utilize resources for further learning