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
