Introduction

Hemothorax is defined as the presence of blood in the space between the visceral and parietal layers of the pleural cavity. This potential space can be filled by most of the patient's blood volume, and when it fills rapidly can lead to death from hypovolemia. When it develops slowly or is of smaller volume it may remain undetected, leading to adhesion formation and restriction of lung expansion.

Hemothoraces frequently follow blunt and penetrating trauma but also arise in other situations. The management varies from simple observation to emergency thoracotomy depending on factors apart from the volume of blood present. In well-resourced facilities selective thoracotomy or thoracoscopy can be the most appropriate therapy. Where resources are limited and experienced surgeons are not available, the optimal management is more likely to be simple drainage or aspiration. There is no uniform method for treating hemothoraces, and there is often variation in management techniques within individual units. In the following account basic principles are emphasized in the light of broad experience and well-established data.

The presence of blood in the pleural space without air or fluid in the absence of trauma is rare. It is surprising that even in hemophilia and other hemorrhagic diseases hemothorax is unusual. In the critical care environment the source of blood is the most important feature. The prognosis is closely related to the anatomical and physiological cause of the hemothorax rather than the volume of blood. Spontaneous hemothorax is uncommon, and at one time was associated with a mortality of around 15 per cent. When continuous excessive blood loss occurs there is usually retained clot and accumulation of blood within the thorax. In postoperative hemorrhage there is frequently a larger volume of clot within the pleural space than liquid blood in the drainage bottles. A small elderly female may have significant tension in a hemithorax containing 1 liter, while a large fit young man will have little tension in a hemithorax containing 4 liters. It is the physiological status of the patient which determines the urgency in management.

Mechanisms must be understood when dealing with hemothorax. Bleeding from a contained dissecting aortic aneurysm may leak into the pleural space. Hemorrhage from the abdominal cavity can present as hemothorax. The most common explanation for spontaneous presentation is in association with a pneumothorax from which air has been absorbed. Bleeding may occur synchronously with pneumothorax or may follow the absorption of air from the space. Bleeding following a long delay from surgery or insertion of a chest drain usually signifies erosion associated with infection and necrosis.

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