Traumatic Hemothorax

Case: 18 y/o M is wheeled in with a stab wound to the left chest. VS: HR 130, BP 95/45, RR 30, SpO2 92% on 15L NRB. Pt is maintaining airway, no tracheal deviation, diminished BS on the left, strong distal pulses. You place a left-sided 36F chest tube with immediate blood return. 

What are the possible etiologies of traumatic hemothorax?

Laceration/injury to the heart, major vessels, intercostal vessels, mammary arteries, thoracic spine, diaphragm or lung parenchyma. 

How reliable is the FAST exam in diagnosing a hemothorax?

Sensitivity is 92-96% however bear in mind that the presence of subcutaneous air or concomitant PTX may obscure the underlying blood.

How much blood must be present to diagnose a hemothorax on CXR?
For upright CXRs, 150-300mL of blood causes blunting of the costophrenic angle. However, most trauma will have their CXR done in a supine position, which has a low sensitivity 35-60%. It may take 1L of blood distributed throughout a supine hemithorax to develop haziness on a supine film!

What defines a massive hemothorax?

-Immediate drainage of 1.5L (or 15mL/kg) or 1/3 of blood volume
-Drainage of 200mL/h (or 3mL/kg/h) x 2-4 hours plus persistent need for blood products

Other definitions:

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How to manage a massive hemothorax post thoracentesis?

Address hypoxia by keeping patient on oxygen and may attempt to position so that affected lung is down (if permitted by lack of other injuries). Resuscitate with 1:1:1 blood products. These patients benefit from thoracotomy in the OR as soon as possible. 

What are the long-term complications of not adequately draining a hemothorax?

Retained hemothorax consisting of clotted blood can form, which is not easily drainable by a chest tube. A traumatic hemothorax is also a nidus of infection; these patients are at risk of developing empyemas.

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