A 31 year old man is transferred from another hospital following
a kick to the left chest. Initial chest X-ray showed a large haemothorax.
was taken to the CT scanner, by which time the whole chest had filled
with blood and there was radiological evidence of tension.
CTs show a left hemithorax full of
blood, with the lung compressed down to a very small volume. The
heart, trachea and mediastinal structures are shifted to the right.
By this time the patient was in respiratory distress with a respiratory
rate of 40 with shallow, painful respiration. Pulse was 105 and
blood pressure 110/60.
A left sided chest drain was placed
and the patient transferred to our institution. Over the next 12
hours the patient drained 4000mls of venous blood from the left
chest, but the patient remained haemodynamically stable. The bleeding
slowed and stopped. Thoracoscopic washout was performed to evacuate
approximately 1000mls of retained clot on day 3 and the patient
was discharged home on day 7.
Massive haemothorax is a well-recognised
condition and may often produce radiological evidence of tension.
Aprat from tracheal & mediastinal deviation, the other signs
are not present. The affected hemithorax is dull to percussion
and there is no distension of neck veins or raised jugular venous
pressure due to the hypovolaemic state.
This patient should have had a
chest drain placed following the initial chest X-ray. While most
venous bleeding will stop eventually there is no credence to the
myth that the build-up of tension in the left chest will tamponade
the bleeding - as evidenced by the dramatic collapse of the left
lung and shift of the mediastinum visible on the CT scan. There
is little indication for a CT scan in the emergent management
of this patient, though a scan of the abdomen did rule out associated
trauma.org (8:2) February 2003