Hemothorax - is the accumulation of blood between the pleural sheets, resulting from bleeding of the major pulmonary and thoracic vascular trauma of the chest wall, diaphragm and mediastinal organs.
Unlike pneumothorax, a mechanism which is similar to the appearance of hemothorax when congestion of blood in the pleural cavity to the fore symptoms of respiratory failure and hypovolemic syndrome, which is often complicated by the development of signs of hemorrhagic shock and death.But in most situations with an open chest cavity damage develop signs gemopnevmotoraksa.
incidence of this disease is not less than 25% of all cases of thoracic trauma.Hemothorax belongs to the category of urgent clinical entities of diseases that require early diagnosis and emergency medical intervention.
most common etiopathogenetic factor is the emergence of traumatic hemothorax closed injury of the chest cavity with damage to the bone skeleton.With such exposure, a so-called
independent form of postoperative hemothorax is considered a type that should not be construed as an iatrogenic effects.In the postoperative period in patients with thoracotomy often occurs clotted hemothorax, which does not pose a threat to the patient's life.Very rarely haemothorax acts as a complication of pleural puncture or catheterization of the subclavian vein, where there is little damage to the vessel.
Some existing pathology of the patient's thoracic cavity may be complicated by the development of hemothorax.These conditions should include destructive forms of tuberculosis, cancer of the lungs and mediastinum, pleura carcinomatosis, aneurysmal expansion of intrathoracic arteries.Moreover, chronic diseases of the blood in violation of coagulative properties can provoke the development of hemothorax on the background of well-being.
pathogenetic mechanisms of accumulation of blood in the pleural cavity are the same for all types of hemothorax and based on either traumatic defect, either increased vascular permeability.The volume of accumulated blood not only depends on the degree of violation of the integrity of the lung, but also on the location of the damage.Vascular lesions of small and medium caliber, located in the peripheral regions of the lungs, is developing a small hemothorax.In a situation where there is damage to the walls of the large arterial vessels, is developing a total hemothorax, accompanied by severe hemodynamic disorders and death.
Development signs curled hemothorax due to massive intrapleural bleeding, in which the clotting process is most active during the first 4-5 hours after the onset of bleeding.The risk of coagulated hemothorax increased in patients suffering from disorders of blood coagulation properties.
Symptoms and signs of hemothorax
clinical picture in hemothorax depends on the amount of extravasated blood in the pleural cavity, the presence or absence of compromising the integrity of lung tissue, as well as the state of the structures of the mediastinum.
In a situation where there is a small hemothorax, the patient does not show active complaints and physical signs are minimal or absent.In some cases, patients complain of the presence of a dull pain in the affected side of the chest without irradiation, and shortness of breath.
vascular lesions caliber patient develops a typical symptom characteristic manifestations of which is the expression of hemodynamic and respiratory disorders.The prevailing majority of patients with hemothorax complain dagger sharp pain in the chest cavity with half the typical radiating to the upper body and back, aggravated by the slightest movement of the chest and breathing.Hemodynamic disturbances manifest as hypotension and heart palpitations.
signs of severe hemothorax is the development of symptoms of hypovolemic shock in the form of occurrence of severe weakness, dizziness, and various degrees of impaired consciousness (syncope, stupor, coma).
Traumatic hemothorax almost 70-80% of cases is caused by rib fractures of different localization with displacement of bone fragments.In this situation, the main feature of compromising the integrity of the pulmonary parenchyma is the emergence of hemoptysis in a patient.Palpation of the chest causes a sharp pain and abnormal motility determined rib frame.In marked displacement of bone fragments show signs of intramuscular and subcutaneous emphysema (the presence of soft tissue bruising and crepitations palpation of soft tissues).
coagulated hemothorax has no specific clinical manifestations and is characterized by a discomfort in the chest cavity during breathing movements, as well as moderate-severe respiratory disorders.
Prolonged hemothorax conditions for infection and the development of pleural sheets clinic empyema (febrile type of fever, intoxication syndrome, cough with copious amounts of purulent sputum).
correctness of the initial examination of the patient with the use of all possible physical methods of examination (palpation, percussion and auscultation of the lungs and heart), almost 70% of cases can reliably establish the diagnosis "haemothorax" subject to known its cause (the presence of injury of the thoracic cavity in history).If visual contact with the patient's attention is drawn to the expressed pallor, high humidity and reducing the temperature of the skin.The damaged part of the chest is less actively involved in the act of breathing, you may experience a local bulging intercostal spaces on the affected side.When making the percussion of the chest over the place of the alleged accumulation of blood (usually in the lower lung fields) is determined by a dull sound, and auscultation signs of hemothorax is a complete absence of vesicular breath over the affected area.
haemothorax Left-hand with a large amount of blood in the pleural cavity is characterized by symptoms of displacement of certain structures of the mediastinum, which manifests itself in the form of a displacement of the boundaries of cardiac dullness.
Usually hemothorax has a favorable outcome, which is the residual resorption of blood clots, which are in the pleural cavity and the formation of small linear pleural moorings.This outcome is possible only if adequately conducted treatment in full.In some cases, accompanied by hemothorax pleural infection and the appearance of signs of empyema, which in the absence of massive antibiotic therapy, can cause the development of infectious-toxic shock and even death.
Among all known laboratory and instrumental methods of diagnosis of hemothorax most appropriate are: ray imaging techniques (X-ray, ultrasound scan of the pleural cavities, computed tomography and magnetic resonance imaging) bronchoscopy with concomitant biopsy, cytological analysis of sputumto determine the presence of atypical cells, diagnostic thoracentesis to conduct trial Rivilua Gregoire and Petrov.
most simple in execution and in most cases in terms of informative confirmation hemothorax ray diagnostic method is a review of the chest X-ray.With a view to the diagnosis of a small amount of blood in a particular pleural recommended radiography in the standing position or lateroposition.
Depending on the volume of intrapleural bleeding there are certain signs skialogicheskie:
- the presence of a blackout kosovoskhodyaschey a clear upper boundary, homogenous structure and high intensity or total blackout throughout the lung fields;
- lack of a clear structure of the bone-phrenic or cardio diaphragmatic pleural sinuses;
- lack of visualization of the diaphragm on the affected side;
- shift of mediastinal structures and varying degrees kollabirovaniya easy.
X-ray examination may be signs of a limited hemothorax that occur in patients with adhesive changes the pleural cavity.Narrow hemothorax visualized as darkening with clear contours, homogeneous structure and, as a rule, these changes are located in the middle and lower lung fields.
Standard radiography only allows to evaluate the existence of liquid level in the pleural cavity and is expected to reveal the amount of the accumulated blood.Thus, all available total blackout hemithorax indicates that in the pleural cavity is not less than two liters of blood, and if the upper limit dimming level is at the rear edge of the second segment, the blood volume is from one to two liters.Paid to the expert assessment of ultrasound diagnosis is even a meager amount of blood.
After determining the presumptive presence of blood in the pleural cavity of the product it is advisable to diagnostic thoracentesis with aspiration of the contents of the pleural cavity.This manipulation is conducted in order to establish evidence of ongoing bleeding and infection of the pleural layers.The criterion infected hemothorax is a positive test Petrova in which detected reduction in the transparency and the availability of sediment aspirated blood.If you suspect an infection of the pleural cavity must be completed only cytology, but aspirate bacterial research.Predetermines the sign of the continuing intrapleural bleeding is positive test Rivilua Gregoire, which implies the presence of signs of aspirated blood clotting.
most informative method of diagnosis, allowing diagnosis of a small amount of blood in the pleural cavity, as well as the type of coagulated hemothorax, a diagnostic thoracoscopy.Note that for thoracoscopy should be strict indications: a penetrating stab wound to the chest with the localization below the seventh intercostal space (to avoid thoracoabdominal injury), injury of mediastinal organs (heart and great vessels), the presence of a large amount of blood during thoracentesis (more than 1liters) pnevmogemotoraks.
Like any invasive procedures, thoracoscopy has contraindications for use, among which should be noted such as hemorrhagic shock, cardiac tamponade, and obliteration of the pleural cavity.
treatment of patients with hemothorax should deal with doctors in various fields: the surgeon, pulmonologist, Angiology and Rehabilitation.
success of the application of certain therapeutic procedures when hemothorax depends primarily on early diagnosis of the terrible state of the patient's life, and in a timely manner to provide first aid qualified.
treatment of any form of hemothorax should be conducted as soon as possible, because the blood is one of the most favorable nutrient medium for the propagation of pathogens.The most common pathogens infected hemothorax are obligate anaerobic flora.
Conservative treatment with antibiotics and anti-inflammatory drugs are used only in the case of small hemothorax without having expressed frustration the patient's health.Conservative treatment should be under the mandatory X-ray control.The optimum period of absorption of small hemothorax considered from two weeks to one month.In order to accelerate the resorption of blood clots in patients with signs of coagulated hemothorax advisable to appoint parenterally proteolytic enzymes (chymotrypsin 2.5 mg intramuscularly, 1 time a day rate of not less than 15 injection), as well as through direct irrigation pleural cavities solutions urokinase, streptokinase.
First Aid hemothorax prehospital work is adequate anesthesia with 2 ml of 50% solution of Analgin by intramuscular infusion, oxygen therapy.In a situation where there are signs of hypovolemic shock advisable reopoliglyukina immediate introduction of 400 ml intravenous-drip.
patients with signs of hemothorax compulsory subject hospitalization for surgical instrumental methods of diagnosis and adequate treatment strategy.Note that the preferred method of transportation of the patient is evacuated on a stretcher in the "half-sitting."
presence of a large volume of patient blood in the pleural cavity, is accompanied by disorders of central hemodynamics and is in need of adequate cardiovascular drug therapy (Mezaton 1% solution in 2 mL dose by subcutaneous injection of 0.06% solution Korglikon dissolved in 1 ml of 10ml of isotonic sodium chloride solution by intravenous infusion).
In a situation where there is a massive intrapleural bleeding, accompanied by hemorrhagic anemia, the patient is recommended substitutions red blood cell transfusions of whole blood or prevent the development of hypovolemic shock.
algorithm antishock measures in hemothorax is to carry out the following medical procedures:
- the imposition of a tight bandage, soaked in antiseptic;
- access of oxygen;
- holding vagosympathetic novocaine blockade;
- infusion therapy (40% glucose solution, intravenous drip, 5 ml of a 5% solution of ascorbic acid intravenously, intramuscularly Hydrocortisone 25-50 mg, 10% calcium chloride solution 10 ml i.v.).
In the hospital, primary care is to carry out the primary surgical treatment of existing wounds of the chest cavity and in a situation where there are no signs of damage to vital organs and structures of the chest cavity, produced hemostasis and suturing.If there is damage to the chest, it is necessary to urgently prepare a patient for an extended thoracotomy with concomitant damage to the suturing.
absolute indication for extended thoracotomy in order to establish the location and closure of the existing damage to a positive test Rivilua Gregoire, indicating continued bleeding into the pleural cavity.
thoracotomy After making sure the pleural cavity on the affected side are installed drains diameter of 2-2.5 cm for further allocation accumulating blood.The most appropriate localization to install drainage is the sixth intercostal space on the mid-axillary line.Isolation of bloody fluid is an active or passive manner.The indication for removal of the drainage tube is a complete cessation of discharge of fluid from the pleural cavity, and this manipulation is made subject to the rules of antisepsis.
If indications for thoracotomy have been identified, in order to remove the blood from the pleural cavity is performed thoracentesis.The most physiologic in this situation is the place for the puncture is the seventh intercostal space on zadnepodmyshechnoy line, but is preferably carried out under the supervision of thoracentesis ultrasonic sensor.Pleural puncture is performed to eliminate the growing respiratory and hemodynamic disorders.