The following systemwise presentation of signs and symptoms is seen in patients suffering from hemothorax:

• General appearance: Patients usually presents with anxiety and restlessness due to the profound hypovolemic shock caused by the internal bleeding in the pleural cavity. 
• Integumentary system: The skin will appear pale, cold and clammy due to the impending hypovolemic shock.
• Head and neck: The jugular veins may appear bounding and engorged due to pulmonary hypertension.
• Chest and heart: Chest pain may ensue as the blood collection irritates the pleural nerves. Hypovolemic shock may lead to tachycardia and hypotension in patients with hemothorax. Patients may present with shallow breathing due to the respiratory response of the patient to the space limiting expansion of the blood in the pleura. The region of the hemothorax in the chest may be devoid of breath sounds during auscultation and may be dull upon percussion.
• Renal: Oliguria may be an early sign of hypovolemic shock.
• Extremities: Pulses in the extremities will appear thread-like and weak due to the massive exsanguination of blood within the pleural cavity.
• Neurologic: When patients are brought in the emergency room as unconscious and obtunded, they may be suffering from late symptoms of shock and may require immediate emergency care. 

A good clinical history and physical examination may easily seal the diagnosis of hemothorax. However, these laboratory tests and examinations may prove to be helpful in the definitive diagnosis and the management of the hemothorax:

• Chest radiograph (X-ray): This imaging modality may reveal the exact location of the hemothorax and give the clinician the idea on the extent of the injury to the lungs.
• Computed tomography (CT-scan):  This confers a more detailed view of the lung parenchyma and the major vessels that might have been severed to cause the blood collection in the pleural space. The CT scan can accurately compute the volume exsanguinous blood in the pleural space.
• Pleural tap or thoracentesis: The laboratory analysis of the pleural fluid will confirm whether the blood in the pleura is a true hemothorax or just a bloody pleural effusion.

Patients presenting in the emergency room with signs of hemothorax should be dealt with promptly. The stabilization of the cardiopulmonary status is given utmost priority followed by the prompt evacuation of the collected blood and pneumothorax in the pleural space. The application of a tube thoracostomy in patients with hemothorax remains to be the primary mode of treatment.

The use of a Video Assisted Thoracoscopic Surgery (VATS) allows the direct removal of clots in the pleura and the precise placement of the chest tubes. VATS may also be used in the direct ligation of chest bleeders to control the progression of hemothorax in some cases [6]. Even in late cases of retained clots, VATS may prove to be useful to evacuate these clots when the patient is already stabilized [7].

In cases of non-traumatic hemothorax, the open thoracotomy approach may prove to be indispensable. This procedure is most useful in the following intrathoracic surgical procedures: stapling of bullous lesions, resection of cavitary diseases and necrotic lung tissue, sequestration of arterio-venous malformation, and repair of aortic aneurysm [8].

Residual pneumothorax is treated by fibrinolysis through the chest tube using streptokinase or urokinase in saline solution [9]. The regular instillation of fibrinolytic compounds in the pleura carries a success rate of up to 92%.

In general, the outcome for traumatic hemothorax is good due to the advances in the health care delivery. Mortality rates in hemothorax varies directly to the severity of the thoracic injury and the important structures involved therein. Retained hemothorax, empyema and fibrothorax is associated with poor morbidity rating. The prompt surgical evacuation of the retained hemothorax is associated with an excellent prognosis.

Complications

The following medical conditions are known to be the common complications of hemothorax:

• Atelectasis
• Retained hemothorax
• Respiratory failure
• Fibrothorax or scarring of the pleural membrane
• Empyema
• Pneumothorax
• Hypovolemic shock
• Death

The following clinical conditions may contribute or directly cause hemothorax in patients:

• Chest trauma
• Blood dyscrasias or clotting defects
• Heart or lung surgery (iatrogenic)
• Pulmonary ischemia or infarction
• Pulmonary or pleural cancers
• Vascular tear
• Tuberculosis

In the United States, the number of hemothorax cases related to chest trauma approximates 300,000 cases per year [3]. Statistics in a trauma center have confirmed that the relative mortality rate of hemothorax among children reaches 57.1% in blunt chest trauma [4]. In penetrating chest injuries, morbidity was slated at 8.51% complicating to either atelectasis, lung infection, intrathoracic hematoma, wound infection, pneumothorax, or sepsis [5].

The pathophysiology of hemothorax is governed by two basic responses namely: the hemodynamic response, and the respiratory response. Any disruption in the integrity of the chest wall to the lung parenchyma may cause significant bleeding that can fill the pleural space. Given that the pleural cavity can hold up to 4 liters of fluids, an occult exsanguination of blood can cause hypovolemic shock to a patient without eminent bleeding from the outside. Shock can occur if blood loss amounts to more than 30% of the blood volume or approximately 1,500 ml in a 70kg man.

Early symptoms of shock includes tachypnea, tachycardia and decreased pulse pressure. While the blood collects in the pleural space, the lung parenchyma is consequently displaced and unable to expand effectively. The significant impairment in the oxygen exchange in the lungs due to the collection of blood constitutes the respiratory response phase of the hemothorax.

Traumatic hemothorax can be prevented by avoiding activities that may lead to blunt injuries to the chest wall. Seat belts must always be in place while driving. Drivers must cautiously drive motorcycles and bicycles to avoid road accidents. Patients diagnosed with tuberculosis must submit to immediate treatment and constant chest X-ray monitoring to prevent spontaneous hemothorax and pneumothorax [10].

Hemothorax is a clinical condition characterized by the presence of blood between the chest wall and the lung parenchyma (pleural space). The hemorrhage in hemothorax may originate from the lung parenchyma, the great vessels, the heart or the chest wall.

Hemothorax is usually caused by blunt trauma to chest wall but may infrequently be due to diseases conditions, iatrogenic induction or spontaneous [1]. Hemothorax needs immediate evacuation to prevent life threatening complications. To this day, the use of trocar and cannula through an incision in the chest wall to drain the blood and trapped air is still the standard practice [2].

Definition

Hemothorax is defined as a clinical condition characterized by the presence of blood in the pleural space.

Cause

Chest trauma, bleeding defects, chest surgery, pulmonary infarction, cancers and vascular problems are common causes.

Symptoms

Patients will present in anxiety and is usually restless. Signs of shock may ensue with a progressively bleeding hemothorax.

Diagnosis

A thorough clinical history and physical examination. Ancillary procedures like laboratory pleural fluid analysis and imaging techniques may also be implored.

Treatment and follow-up

Tube thoracostomy remains to be the primary mode of treatment, Open thoracotomy may also be an option, the use of VATS for hemothorax evacuation in stabilized patients may also be done, and pleural fibrinolysis may also be done to eliminate the residual pneumothorax. 

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