Hemothorax

Basics

Accumulation of blood in the intrapleural space after blunt/penetrating chest trauma or other nontraumatic etiology. Bleeding is usually a result of disruption of the tissues/vessels of the chest wall, pleura, or intrathoracic structures:
- Results in decreased vital capacity, hypoxia, and respiratory compromise
- Loss of large intravascular volume results in hemodynamic instability and hemorrhagic shock
- Massive hemothorax can cause increased intrathoracic pressure, resulting in compromised venous return and decreased cardiac output
Rarely a solitary finding in blunt trauma:
- Commonly associated with pneumothorax (25% of cases), extrathoracic injuries (73% of cases), and pulmonary contusion
Large hemothoraces cause the release of substances that can act as anticoagulants and contribute to continued intrathoracic bleeding
If left untreated, can lead to empyema and fibrothorax (lung trapping due to adhesions)

Traumatic injuries (including iatrogenic) to major blood vessels:
- Common vessels, including intercostal artery, internal mammary artery, pulmonary artery, pulmonary vein, aorta, vena cava, and heart are associated with hemorrhage into the thoracic cavity
Traumatic lung parenchymal injuries:
- Often stops spontaneously as a result of low pulmonary pressures and high concentrations of thromboplastin in the lung
- Often associated with pneumothorax
Nontraumatic or spontaneous hemothoraces:
- Very rare
- Consider coagulation disorder, malignancy, primary vascular event (such as aortic dissection, ruptured aneurysm), PE with infarction, infection (TB), bullous emphysema, pulmonary AV malformation, lobar sequestration
Torn pleural adhesions as a complication of spontaneous pneumothorax or tube thoracostomy

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