12.

HEMOTHORAX

PLEURAL DISEASES SERIES 08 BY WIDIRAHARDJO

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Hemothorax is the presence of a significant amount of blood in the pleural space. Most hemothoraces result from penetrating or nonpenetrating chest trauma.

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On rare occasions: from iatrogenic manipulation such as the placement of central venous catheters percutaneously by the subclavian or internal jugular route or from translumbar aortography, pulmonary embolism or rupture of an aortic aneurysm and catamenial hemothorax

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Blood entering the pleural space coagulates rapidly, but result of physical agitation produced by movement of the heart and the lungs, the clot may be defibrinated. Loculation occurs early in the course of hemothorax, as with empyema.

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A hemothorax should be considered only when the pleural fluid hematocrit is equal to or greater than 50% of the peripheral blood hematocrit. The treatment of choice for patients with traumatic hemothorax is the immediate insertion, except if only a very small hemothorax, of a largelargebore chest tubes (size 36 to 40 F) chest tube.

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The advantages of the immediate institution of tube thoracostomy are: a. Allows more complete evacuation of the blood from the pleural space; b. Stops the bleeding if the bleeding is from pleural lacerations; c. Allows one to quantitate easily the amount of continued bleeding;

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d. May decrease the incidence of subsequent empyema because blood is a good culture medium; e. The blood drained from the pleural space may be autotransfused; f. The rapid evacuation of pleural blood decreases the incidence of subsequent fibrothorax.

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Chest tubes were checked every 6 hours and were removed when there was no air leak and there was less than 50 mL drainage in the previous 6 hours. Vascular injury is suggested if the initial chest tube output is more than 1,500 mL.

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Immediate thoracotomy or thoracoscopy is indicated for suspected cardiac tamponade, vascular injury, pleural contamination, debridement of devitalized tissue, sucking chest wounds, or major bronchial air leaks.

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Continued pleural hemorrhage, i.e. more than 200 mL/hour and shows no signs of slowing is another indication for immediate thoracotomy or video-assisted videothoracic surgery (VATS). The four main pleural complications of traumatic hemothorax are the retention of clotted blood in the pleural space, pleural infection, pleural effusion, and fibrothorax.

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Catamenial Hemothorax Catamenial hemothorax is a hemothorax that occurs in conjunction with menstruation and it is unusual. It is associated with pelvic abdominal and pleura endometriosis. Catamenial hemothorax can be treated by suppressing ovulation using oral contraceptives or progesterone or suppression of gonadotropins using danazol or gonadotropin releasing hormone.

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Hormonal therapy frequently fails. So chemical pleurodesis can be performed, and if this measure fails, total hysterectomy with bilateral oophorectomy can be done.