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Home > Case Presentation

Case Presentation

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.

Discussion

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.

 

Comments

On 06/29/2007, surgery2 commented:

Was thoracoscopic wash out necessary? Can uninfected pleural cavity ‘handle’1000mls of clots like peritoneal cavity?

On 07/02/2007, basab.bhattacharya commented:

so what was the indication for a ct in this instance?

On 07/03/2007, Karim commented:

Evacuation of retained clot is probably indicated if volumes are large, as the clot may become secondarily infected or, more commonly, does not but leads to restricted lung capacity and decreased exercise tolerance.  What constitutes a large collection is not clear.  Thoracoscopic washout appears to be better than other methods of evacuation at this stage.

Was a CT indicated?  Certainly there is an argument that a chest drain should have been placed prior to CT.  The patient had suffered blunt chest trauma and the CT was performed primarily to assess the abdomen in this case.

On 07/04/2007, makedon commented:

In case that we are not near a hospital and we cannot evacuate our injury for a significant amount of time (e.g. more than 5 hours), what will be the best treatment for a massive hemothorax? If, after a chest tube has been applied, blood continues to come out with a rate of > 400 ml/hour, should we clamp the tube or what else should we do?
Dimitris Giannoglou

On 07/10/2007, Karim commented:

No, clamping the tube has no effect on the amount of haemorrhage - the blood just collects in the chest and further compromises respiratory function.

Patients with active & continued bleeding from the chest need an urgent thoracotomy - or immediate transfer to a place where they can get one!

There is never an indication for clamping of a chest tube.

On 07/10/2007, Dr.Suhail yaqoob commented:

Is hemodynamic stability the only criteria for non-operative treatment.In this case there must have been a considerable initial drainage that too persistent.And how to comment about the blood being venous in a significant blood volume loss.

On 09/03/2007, sarfile commented:

so the management of hemothorax depends upon circumstances ie pre hospital in emergency room and operation theater.But early drainage with volume replacement,nsaid and secondary evaluation till reaches tertiary care.bedside ultra sound is better choice and time with money saving to exclude intra abdominal injuries.

On 09/10/2007, Zane commented:

A total of 5000ml of fluid was removed from the hemithorax, an entire blood volume, yet remained normotensive. Is it fair to say tension haemothorax is a complication of massive blood transfusion/fluid replacement?

On 09/14/2007, sarfile commented:

point to be noted here is not 5000ml lost but the good management of patient with fluid and blood replacement that saves the life of the patient. As far as complication of massive blood and fluid replacement is concerned….it might led to physiological derailment rather than anatomical issue.

On 09/23/2007, muhammad commented:

Eventhough we tranfuse some amount of blood to mantain the haemodynamic status but it still wiil not improve patient’s condition if the bleeding did not stop
so are there any medication or method to stop the bleeding as immediete as posible before the thoracotomy perform?

On 09/23/2007, Karim commented:

The short answer is no.  If the patient needs a thoracotomy then any delay will worsen outcomes. 

Of course, coagulopathy needs to be aggressively treated with blood products and possibly other adjuncts such as antifibrinolytic or recombinant factor VIIa (both currently undergoing randomised trials) but this is during, not before, thoracotomy and haemorrhage control.

On 09/24/2007, sarfile commented:

yes I do agree with Karim’ noble approach.

On 03/11/2008, matt151617 commented:

Amazing the amount of blood that collected there (and was later removed).  The left lung looks almost non-existent.  Great job that the patient walked away from that alive.

On 07/25/2010, Dr Chughtai commented:

why the thoracoscopic intervention not done and pt was resuscitated when he poured 4lts of blood in 12 hrs

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