Hemothorax Overview and Practice Questions Vector

Hemothorax: Overview and Practice Questions (2024)

by | Updated: Apr 21, 2024

Hemothorax, a critical condition characterized by the accumulation of blood in the pleural cavity, presents a significant challenge in both diagnosis and management.

This condition, often resulting from chest trauma or complications of medical procedures, can rapidly deteriorate a patient’s respiratory and hemodynamic stability.

Understanding the pathophysiology, clinical manifestations, and timely intervention strategies is essential to effectively manage a hemothorax, minimize potential complications, and improve patient outcomes.

What is a Hemothorax?

A hemothorax is a medical condition where blood accumulates in the pleural cavity, the space between the lungs and the chest wall. It usually results from chest trauma or surgery, impairing breathing and necessitating prompt medical attention to drain the blood and treat the underlying cause.

Hemothorax Vector Illustration

Causes

A hemothorax can arise from several causes, including the following:

  • Trauma: This is the most common cause. Traumatic hemothorax can result from blunt or penetrating injuries to the chest, such as those sustained in vehicle accidents, falls, or stabbings/shootings.
  • Surgical Complications: Some surgical procedures, especially those involving the lungs, heart, or major chest vessels, can inadvertently lead to hemothorax.
  • Ruptured Blood Vessels: Conditions leading to the rupture or tearing of blood vessels in the chest, such as a ruptured aortic aneurysm, can cause hemothorax.
  • Coagulopathy: Disorders of blood clotting, whether due to inherited disorders (like hemophilia), liver disease, or the effects of certain medications (like anticoagulants or blood thinners), can lead to bleeding into the pleural space.
  • Lung or Pleural Diseases: Lung cancers, pleural tumors, or other diseases that erode into blood vessels can cause bleeding into the pleural cavity.
  • Iatrogenic Causes: These are causes related to medical intervention or treatment, such as complications from a central venous catheter placement, lung biopsy, or pleural procedures.
  • Spontaneous Hemothorax: Rarely, a hemothorax may occur spontaneously, often in the context of underlying vascular or connective tissue diseases (e.g., vasculitis, Ehlers-Danlos syndrome).

Note: Prompt recognition and treatment of a hemothorax are crucial to prevent complications like lung collapse, infection (empyema), and fibrothorax (where the pleura becomes thick and fibrous, restricting lung expansion).

Signs and Symptoms

The signs and symptoms of a hemothorax may include:

  • Sharp chest pain
  • Dyspnea
  • Tachycardia
  • Tachypnea
  • Diminished or absent breath sounds on the affected side
  • Restlessness
  • Cold or clammy skin
  • Hypertension
  • Shallow breathing
  • Anxiety

Note: Symptoms depend on the amount of blood accumulation and the rate at which it accumulates, influencing the urgency and type of treatment required.

Diagnosis

Diagnosing a hemothorax typically involves a combination of clinical assessment and imaging studies:

  • Clinical Evaluation: Initial assessment of symptoms like chest pain, difficulty breathing, and signs such as rapid heart rate, low blood pressure, and reduced breath sounds on the affected side.
  • Chest X-ray: Often the first imaging test used. It can show fluid buildup in the pleural cavity, though it may not specifically differentiate blood from other types of fluid.
  • Ultrasound: Bedside ultrasound or focused assessment with sonography for trauma (FAST) can be particularly useful in emergency settings for rapidly detecting fluid in the pleural space.
  • Computed Tomography (CT) Scan: Provides a more detailed image of the chest, helping to confirm the presence of blood and identify the underlying cause, such as fractures, lung injuries, or tumors.
  • Thoracentesis: Involves removing fluid from the pleural space using a needle for diagnostic analysis. The presence of blood in the aspirated fluid can confirm hemothorax.
  • Blood Tests: Can assess overall health and help determine the cause of the bleeding, especially in cases where a clotting disorder is suspected.

Note: The diagnosis is crucial in guiding the appropriate management strategy, including the immediate need for drainage and addressing any underlying conditions.

Treatment

Treatment of a hemothorax focuses on two primary objectives: removing the accumulated blood from the pleural space and addressing the underlying cause.

The management typically involves:

  • Immediate Stabilization: This includes ensuring adequate oxygenation and ventilation, intravenous fluid resuscitation, and blood transfusions if necessary, especially in cases of significant blood loss leading to shock.
  • Chest Drainage: The most common and immediate treatment is the insertion of a chest tube (thoracostomy) to drain the blood. This procedure relieves pressure on the lungs, allowing them to re-expand and function properly.
  • Surgical Intervention: In cases of ongoing bleeding, large-volume hemothorax, or when the blood does not drain adequately through a chest tube, surgical exploration may be necessary. This could include video-assisted thoracoscopic surgery (VATS) or open thoracotomy to control bleeding sources.
  • Addressing Underlying Causes: Simultaneous treatment of the underlying etiology (such as repairing injured blood vessels, treating tumors, or managing coagulopathies) is crucial.
  • Observation and Supportive Care: After the acute issue is addressed, monitoring for complications like infection, lung collapse, or fibrothorax is essential. Pain management and supportive care, including respiratory support if needed, are also important aspects of treatment.

The specific treatment approach depends on the severity of the hemothorax, the patient’s overall health, and the cause of the bleeding.

Multi-disciplinary care involving trauma surgeons, pulmonologists, and other specialists is often required for optimal management.

Hemothorax Practice Questions

1. What is a hemothorax characterized by?
A hemothorax is characterized by the accumulation of blood in the pleural cavity, the space between the lungs and the chest wall. This accumulation can compromise respiratory function and necessitate prompt medical intervention.

2. How will patients with a hemothorax appear?
Cyanotic, tracheal deviation/mediastinal shift away from the affected side, and bruising over the affected area.

3. What will the respiratory pattern look like for patients with a hemothorax?
Tachypnea and a productive cough (i.e., hemoptysis).

4. What type of breath sounds will you hear in patients with a hemothorax?
Diminished or absent on the affected side.

5. What will chest percussions reveal in patients with a hemothorax?
Flat/dull percussion note on the affected side and decreased tactile and vocal fremitus.

6. What type of diagnostic testing should be done for a hemothorax?
Chest x-ray, ABG, and CBC.

7. What will the chest x-ray look like for a hemothorax?
Increased radiodensity, increased whiteness, and a tracheal shift away from the affected side.

8. What will the ABG look like for a patient with a hemothorax?
Acute alveolar hyperventilation with hypoxemia.

9. What will the CBC be like for a patient with a hemothorax?
Reduced RBC, Hbg, and Hct.

10. How can you treat a hemothorax?
Thoracentesis or chest tube to drain blood, oxygen therapy for hypoxemia, hyperinflation therapy, and mechanical ventilation with PEEP for acute ventilatory failure.

11. What is the etiology of a hemothorax?
Blood accumulation in the pleural cavity is often caused by trauma but is also a frequent complication following cardiac or thoracic surgery.

12. What is the chief complaint of a hemothorax?
Shortness of breath and chest pain

13. What would the physical exam reveal in a patient with a hemothorax?
Decreased breath sounds

14. How is a hemothorax diagnosed?
Chest x-ray

15. What does the past medical history of patients with hemothorax show?
Severe chest pain

16. What are the typical vital signs for a hemothorax?
Increased heart rate and blood pressure

17. What cough is manifested in patients with a hemothorax?
Productive cough

18. What is the appearance of the chest like for a hemothorax patient?
Tracheal and/or mediastinal shift away from the affected side with bruising over the affected area.

19. What is the hemothorax respiratory pattern?
Tachypnea and dyspnea, depending on severity.

20. What is the color of patients with a hemothorax?
Cyanotic

21. What are the typical breath sounds for a hemothorax?
Diminished or absent on the affected side, and a pleural friction rub is possible.

22. What assessment data would indicate that the chest tubes have been effective in treating a patient with a hemothorax who has a right-sided chest tube?
There is gentle bubbling in the suction compartment, no fluctuation in the water-seal compartment, 250 mL of blood in the drainage compartment, and the patient is able to breathe deeply without pain.

23. What is the quick definition of a hemothorax?
Blood in the pleural cavity that may result in lung collapse.

24. What is the pathophysiology of a hemothorax?
The pathophysiology of a hemothorax involves the accumulation of blood in the pleural space, typically due to trauma, surgical complications, or rupture of blood vessels. This accumulation leads to compression of the lung on the affected side, impairing oxygen exchange and ventilation. The pressure exerted by the blood can also impede venous return to the heart, potentially causing hemodynamic instability.

25. What is the primary cause of a hemothorax?
The primary cause of a hemothorax is usually trauma, particularly blunt or penetrating chest injuries.

26. What is the incidence of a hemothorax?
Hemothorax occurs in approximately 300,000 cases of trauma per year.

27. What are the complications of a hemothorax?
Mediastinal shift, ventilatory compromise, lung collapse, cardiopulmonary arrest, pneumothorax, and empyema.

28. What is the patient history of a hemothorax?
Recent trauma, recent thoracic surgery, metastatic disease, chest pain, and dyspnea.

29. What are the physical findings of a hemothorax?
Physical findings of a hemothorax typically include reduced or absent breath sounds on the affected side, dullness to percussion over the area with blood accumulation, rapid breathing, and signs of shock like rapid heartbeat and low blood pressure, particularly in large hemothoraces.

30. What diagnostic laboratory results would be found in patients with a hemothorax?
Pleural fluid analysis shows hematocrit greater than 50% of serum hematocrit; arterial blood gas (ABG) analysis may show increased PaCO2 and decreased PaO2; and serum hemoglobin levels may be decreased, depending on the amount of blood loss.

31. What diagnostic imaging results would be found in patients with a hemothorax?
Chest x-rays and CT scans of the thorax would show the presence and extent of hemothorax and help to evaluate treatment.

32. What would the results of a thoracentesis be for a patient with a hemothorax?
Thoracentesis may yield blood or serosanguineous fluid.

33. What are the common treatment methods for a hemothorax?
Stabilization of the patient’s clinical condition, stoppage of bleeding, thoracentesis, insertion of a chest tube, and auto-transfusion for blood loss.

34. What medications should be given for a hemothorax?
Oxygen, analgesics, and IV fluid therapy.

35. What are the expected outcomes of a hemothorax?
Expressed feelings of increased comfort and decreased pain, expressed feelings of reduced anxiety, fluid volume balance, adequate ventilation and oxygenation, effective breathing patterns, adequate cardiopulmonary perfusion, and no signs of infection.

36. How should the respiratory therapist help treat patients with a hemothorax?
Recommend analgesics as ordered, institute comfort measures and help the patient relax, auscultate lung sounds for changes, give prescribed oxygen based on saturation levels, if indicated, assist with chest tube insertion, ensure the tube is attached to a closed drainage system, arrange for chest X-rays to evaluate chest tube location, ensure follow-up chest X-ray after removal of the chest tube, change the chest tube dressing and provide chest tube care as needed, maintain underwater chest tube drainage as indicated, prepare the patient for surgery if needed,  and obtain specimens for laboratory testing (i.e., ABG analysis).

37. What should be monitored in patients with a hemothorax?
Vital signs, intake/output, chest tube drainage, cardiopulmonary status, closed drainage system function, hemodynamic parameters, ABG results, chest X-ray results, CBC results, complications, and signs/symptoms of infection.

38. What causes blood in the pleural space?
Chest trauma

39. What is suspected in patients with severe chest pain after trauma?
Hemothorax

40. Is there tactile or vocal fremitus with a hemothorax?
Vibration while talking is decreased when a hemothorax is present.

41. Can a pleural friction rub occur in patients with a hemothorax?
Yes, it might be heard since the pleural space will be filled with blood.

42. What procedure is used to drain fluid from the lungs?
Thoracentesis

43. When assessing a patient with a hemothorax, you will most likely find what?
You will most likely find signs and symptoms of shock.

44. A moderate hemothorax diagnosis would be confirmed by the presence of what?
Blood filling approximately one-third of the pleural space.

45. What is the treatment of a hemothorax and pneumothorax?
Recommend a chest tube or thoracentesis in order to drain blood or air from the pleural space.

46. What assessment findings would you expect with a hemothorax?
Chest pain, dyspnea, and tachycardia.

47. Is there a tracheal shift when a hemothorax is present?
Yes, the trachea will shift away from the affected side.

48. What is the diagnostic percussion note for a hemothorax?
Chest percussion would show a dull percussion note.

49. What will the chest x-ray show for a hemothorax?
Partial or complete opacification of the affected side of the thorax.

50. Is mechanical ventilation recommended for a hemothorax?
If ventilatory failure is present, yes, mechanical ventilation would be indicated.

Final Thoughts

A hemothorax remains a notable concern in traumatic injuries and surgical complications, demanding prompt diagnosis and intervention.

The successful management of this condition hinges on early recognition, efficient drainage of the pleural cavity, and addressing the underlying cause.

Continuous advancements in diagnostic imaging and minimally invasive surgical techniques are enhancing treatment outcomes.

However, the emphasis must always remain on preventative strategies and the swift application of evidence-based clinical protocols to mitigate risks and enhance patient survival and recovery in cases of hemothorax.

John Landry, BS, RRT

Written by:

John Landry, BS, RRT

John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.

References

  • Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
  • Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019
  • Broderick, Stephen. “Hemothorax: Etiology, Diagnosis, and Management.” PubMed, Feb. 2013.

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