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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.
The patient 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 as soon as the diagnosis is made. 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 splenic trauma.