Image of the Day 5: Left Hemothorax

This unfortunate young man was brought to the emergency department after involve in motor vehicle accident (Motorbike vs lorry) where his body smashed against the lorry. He sustains loss of consciousness for about 5 minutes, retrograde amnesia, chest pain and shortness of breath. This is the chest x ray of the patient which shows opacity of the left hemithorax up to the upper zone with obliteration of costophrenic angle. The trachea is shifted to the right. After further evaluation, a diagnosis of Cerebral Concussion with left hemothorax was made and chest tube was inserted.

In this section, i will briefly discussed about hemothorax. Bear in minds that hemothorax can be a life threatening or the lethal one for the patient. Small hemothorax sometimes left undiagnosed and patient was discharged home with sequale of progressive on going bleeding.

As in this case, blunt trauma is one of the causes for hemothorax. Others would be penetrating chest trauma, iatrogenic and spontaneous.

As a general rule, if hemothorax is obscuring the costophrenic sulcus or associated with pneumothorax, therefore it should be drained via chest tube. In case of massive hemothorax; 1) More than 1000 cc blood drained post insertion of chest tube, 2) more than 150-200 ml/hr blood drained for 2-4 hours, 3) Requirement of repeated blood transfusion to maintain hemodynamic stability, surgical intervention would be needed.

Other measure needed in resuscitating this patient includes, 1) evaluation of airway patency, 2) two large bore IV access preferably in the ante cubital fossa, 3) Strict I/O monitoring, 4) Folley’s catheter insertion, 5) GXM of at least 3 pints packed cells, 6) Reserve a GSH as we may need to convert to whole blood and DIVC regimes later depending on patient condition. 7) Monitoring of vital sign, blood parameter, baseline ECG, 8) Insertion of Central venous line if required intensive monitoring, 9) KIV for intubation if patient condition deteriorated, 10) Fluid resuscitation and maintenance. Do not use crystalloid containing dextrose even for maintanance as this patient having cerebral concussion, 11) Evaluation of other systemic injury and finally 12) To treat any associated injury (Due to trauma or any metabolic derangement due to hemothorax)

Sequale of hemothorax including residual clot, infected collections, and trapped lung due to fibrothorax or empyema.

Reference:

1. Hemothorax by Mary C. Mancini

http://emedicine.medscape.com/article/2047916

Accessed on 21 April 2012, 1.30 pm