A 65-year-old woman experienced dyspnea, dizziness, and left pleuritic pain several hours after falling down a flight of stairs. Shallow breathing and increased tenderness of the left thoracic wall were evident with palpation. Decreased breath sounds on the left and dullness on percussion were also noted.
Drs Avra Lykouri, V. Archimandriti, V. Baili, and D. Papaioannides of Arta, Greece, report that the patient's supine blood pressure was 110/70 mm Hg, with an orthostatic drop to 95/60 mm Hg. Hematocrit was 28%, and analysis of arterial blood gases revealed moderate hypoxemia. The initial chest film showed several fractured ribs and a homogeneous opacification of the left hemithorax; air bronchograms were absent (A). A thoracentesis revealed gross blood in the left pleural space.
Hemothorax is caused mainly by trauma, pulmonary infarction, tumor, or ruptured aortic aneurysm and is characterized by pleural fluid hematocrit values that are more than 50% of those in the peripheral blood. Hemothorax also can result from invasive procedures, such as placement of central venous catheters, thoracentesis, or pleural biopsy, and has been reported as a rare complication of anticoagulation in patients who are taking heparin and warfarin.
Traumatic hemothorax usually results from penetrating or contused thoracic injuries that lead to rib frac- fracture and damage of intercostal or pulmonary vessels. Hemorrhagic shock can occur with massive blood loss into the pleural space. The shock state may be exacerbated by decreased venous return.
Demonstration of the hemothorax on the initial chest film can be hindered if the patient is supine and the collection of blood is small. Since bleeding may be slow and may not be evident for several hours, serial radiographs must be obtained. The incidence of concomitant pneumothorax is high (about 60% in our experience).
Immediate tube thoracostomy is the initial treatment of patients with hemothorax. Large-diameter chest tube drainage evacuates the pleural space; may stop the bleeding, especially if it originates from a pleural laceration; allows monitoring of the bleeding; and decreases the likelihood of subsequent fibrothorax. Multiple chest tubes may be necessary to completely evacuate the pleural drainage and facilitate reexpansion of the space. The blood must be completely removed from the pleural space so that a restrictive peel will not form around the lung and further impair ventilation. Adequate chest tube drainage and reexpansion of the lung controls bleeding in 95% of patients; thoracotomy to control massive or ongoing hemorrhage is required in about 5% of patients. Surgery is indicated when bleeding exceeds 300 mL per hour.
This patient was given oxygen, a chest tube was placed, and 2 units of whole blood were transfused. The chest tube was removed after 3 weeks; a second chest film showed almost complete evacuation of the pleural space and reexpansion of the left lung (B)