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hemothoraxEmergency medicine The accumulation of blood in the pleural cavity, most often due to trauma, but also due to CA, surgery or infarction; a large hemothorax may cause respiratory failure. Cf Pneumothorax.
he·mo·tho·rax, pl. hemothoraces (hē'mō-thōr'aks, -ă-sēz)
|Mean LOS:||4.1 days|
|Description:||SURGICAL: Major Chest Procedures Without CC or Major CC|
|Mean LOS:||6.4 days|
|Description:||MEDICAL: Pleural Effusion With Major CC|
|Mean LOS:||7.8 days|
|Description:||MEDICAL: Pneumothorax With Major CC|
Hemothorax, an accumulation of blood in the pleural space, affects oxygenation, ventilation, and hemodynamic stability. Oxygenation is affected because the accumulation of blood exerts pressure on pulmonary structures, leading to alveolar collapse, a decreased surface area for gas exchange, and impaired diffusion of oxygen from the alveolus to the blood. Ventilation is likewise impaired as the accumulating blood takes the place of gas in the lungs. Hemodynamic instability occurs as bleeding increases in the pleural space and vascular volume is depleted. Pneumothorax, or air in the pleural cavity, often accompanies hemothorax.
The hemorrhage can occur from pulmonary parenchymal lacerations, intercostal artery lacerations, or disruptions of the pulmonary or bronchial vasculature. Low pulmonary pressures and thromboplastin in the lungs may aid in spontaneously tamponading parenchymal lacerations. Complications of hemothorax include hypovolemic shock, exsanguination, organ failure, cardiopulmonary arrest, and death. Some experts define a hemothorax only when the hematocrit is greater than 50%, as compared to a bloody pleural effusion, but most do not differentiate between the two conditions.
Approximately 150,000 people die in the United States each year from a hemothorax, and most are caused by blunt trauma from motor vehicle crashes (MVCs), assaults, and falls or by penetrating trauma from knives or gunshot wounds. One of every four patients with chest trauma has a hemothorax. Other causes include thoracic surgery, pulmonary infarction, dissecting thoracic aneurysms, tumors, and anticoagulant therapy.
Hemothorax may occur more commonly in people with clotting or bleeding disorders.
Gender, ethnic/racial, and life span considerations
Hemothorax from traumatic injury occurs in both pediatric and adult populations. Because trauma is the leading cause of death in the first four decades of life, hemothorax is most commonly seen in children and young adults. Because they often have fewer compensatory mechanisms to respond to the injury, elderly people with such an injury have higher rates of complications and death. More males than females have injuries each year, but there are no known ethnic or racial considerations.
Global health considerations
Specifically with respect to thoracic trauma, MVCs are the leading cause of injury and they occur most commonly in males 14 to 30 years of age. According to the World Health Organization, falls from heights of less than 5 meters are the leading cause of injury globally, but estimates are that only a small percentage of those are related to thoracic trauma. In areas of civil and political strife and war, ballistic injuries and stab wounds to the chest also cause hemothorax.
Establish a history of the injury. If the patient has been shot, ask the paramedics for ballistic information, including the caliber of the weapon and the range at which the person was shot. If the patient was in an MVC, determine the type of vehicle (truck, motorcycle, car); the speed of the vehicle; the victim’s location in the car (driver or passenger); and the use, if any, of safety restraints. Determine if the patient has had recent tetanus immunization. If the patient can communicate, determine the location of chest pain and whether the patient is experiencing shortness of breath. If there is no chest trauma, establish a history of other risk factors. Determine if the patient has undergone thoracic surgery or anticoagulant therapy. Establish a history of pulmonary infarction, dissecting thoracic aneurysm, or tumor.
The most common symptoms are chest pain and dyspnea, but symptoms vary depending on the nature of the injury and the amount of bleeding. The initial evaluation focuses on assessing the adequacy of the patient’s airway, breathing, and circulation as well as neurological status. The patient should be completely undressed for a thorough visual assessment. The initial evaluation, or primary survey, is completed by the trauma resuscitation team and may occur simultaneously with life-saving interventions as needed.
The secondary survey, completed after life-threatening conditions are stabilized, includes serial vital signs and a complete head-to-toe assessment. Assess the patient for a patent airway. Note respiratory rate, breathing pattern, and lung sounds on an hourly basis. Observe the patient’s breathing; the affected side of the chest may expand and stiffen while the unaffected side rises. Auscultate for lung sounds; the loss of breath sounds is evidence of a collapsed lung. Percuss the lungs; blood in the pleural space yields a dullness. Note signs of respiratory failure; the patient may appear anxious, restless, even stuporous, and cyanotic. If the patient has a chest tube, monitor its functioning, the amount of blood loss, the integrity of the system, and the presence of air leaks.
Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life-threatening if vital structures are perforated. Observe carefully for pallor, blood pressure, and pulse rate, noting the early signs of shock or massive bleeding such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill.
The patient may be fearful or panic stricken because of difficulties in breathing and intense pain. Ongoing assessment of coping strategies of patient and family assists in planning and evaluating interventions. Note that approximately half of all traumatic injuries are associated with alcohol and other drugs of abuse. Assess the patient’s drinking and drug-taking patterns.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Chest x-ray||Air-filled lungs||Opacity at the area of bleeding and lung collapse; blunted costophrenic angle; may show widening of mediastinum and intercostal spaces with depressed diaphragm||Determines the location and extent of lung collapse and fluid accumulation|
|Complete blood count||Red blood cells: 4–6.2 million/μL; hemoglobin: 12–18 g/dL; hematocrit: 37%–54%; white blood cells: 4,500–11,000/μL; platelets: 150,000–400,000/μL||Decreased values reflective of the degree of hemorrhage||Determines the extent of blood loss; note that it takes 2 hr for hemorrhage to be reflected in a dropping hemoglobin and hematocrit after injury|
|Computed tomography||Air-filled lungs with normal lung structure||Localized collection of blood||Determines the location and extent of lung collapse and fluid accumulation if findings from chest x-rays are uncertain; helpful in identifying loculated (saclike) collection of blood|
|Arterial blood gases||Pao2: 80–100 mm Hg; Paco2: 35–45 mm Hg; SaO2: 95%–100%; pH: 7.35–7.45||Hypoxemia; Pao2 < 80 mm Hg; SaO2 < 95%; Paco2 > 45 mm Hg||Determine adequacy of oxygenation; accumulation of blood and air in functional tissue of lungs decreases gas exchange leading to hypoxemia and hypercapnea|
Other Tests: Coagulation studies, ultrasonography, electrocardiogram, thoracentesis, cervical spine x-rays
Primary nursing diagnosis
DiagnosisIneffective airway clearance related to airway obstruction secondary to trauma and tissue damage
OutcomesRespiratory status: Ventilation; Respiratory status: Gas exchange; Symptom control behavior; Comfort level; Infection status; Cognitive ability
InterventionsAirway management; Airway insertion and stabilization; Airway suctioning; Artificial airway management; Oxygen therapy; Respiratory monitoring; Ventilatory assistance; Vital signs monitoring
Planning and implementation
Treatment of a hemothorax focuses on stabilizing the patient’s condition by maintaining airway and breathing, stopping the bleeding, emptying blood from the pleural cavity, and re-expanding the underlying lung. Mild cases of hemothorax may resolve in 10 days to 2 weeks, requiring only observation for further bleeding. More severe cases of hemothorax (hemorrhaging that arises from arterial sites or major hilar vessels) generally require aggressive surgical intervention. Autotransfusion, a system that allows blood removed from the pleural cavity to be returned to the patient intravenously, is useful in the initial management of the patient with hemothorax. Reinfusion of shed blood from the chest injury can be accomplished by a variety of techniques. Significant blood loss may lead to hypovolemic shock.
A tube thoracostomy is the treatment of choice for hemothorax; approximately 80% of penetrating and blunt trauma can be managed successfully with this procedure. A hemothorax with a volume of 500 to 1,500 mL that does not continue to bleed can be managed with a chest tube alone. A massive hemothorax with an initial volume of 1,500 to 2,000 mL or one that continues to bleed between 100 and 200 mL per hour after 6 hours is an indication for a formal thoracotomy. Placement of more than one chest tube may be necessary to drain a hemothorax adequately. After the procedure is completed, a repeat chest x-ray helps identify chest tube position and determines results of hemothorax evacuation. If drainage is not complete, then placement of other drainage tubes may be necessary. The preferred procedure to accomplish the evacuation of the pleural space in this situation is video-assisted thoracic surgery (VATS) operative procedure.
An emergency thoracotomy at the bedside may be necessary in the setting of a massive hemothorax with accompanying hemodynamic instability. The approach is a left anterolateral incision and is reserved for those patients who are in a life-threatening situation. A formal thoracotomy performed in the operating room is accomplished by a variety of incisions. Once exposure is obtained, lung parenchyma and vascular structures, including the great vessels, can be evaluated and repaired.
|Medication or Drug Class||Dosage||Description||Rationale|
|Antibiotics||Varies with drug||Physicians may follow cultures of wounds, urine, blood, and sputum rather than use prophylactic antibiotics||Protect from or combat bacterial infections|
|Analgesics||Varies with drug||IV morphine sulfate provides pain control and can be reversed with naloxone if complications occur||Reduce pain so that they increase mobility|
Other Drugs: Some experts recommend intrapleural instillation of fibrinolytic agents such as streptokinase or urokinase to remove residual hemothorax if chest tube drainage is inadequate. Patients with significant chest trauma causing a hemothorax may benefit by the placement of an epidural catheter for pain management. A tetanus booster is administered to patients with chest trauma whose immunization history indicates a need or whose history is unavailable.
The most critical nursing intervention is maintaining airway, breathing, and circulation (ABCs). Have an intubation tray available in case endotracheal intubation and mechanical ventilation are necessary. Maintain a working endotracheal suction at the bedside as well. If the patient is hemodynamically stable, position the patient for full lung expansion, using the semi-Fowler’s position with the arms elevated on pillows. Because the cervical spine is at risk after injury, maintain body alignment and prevent flexion and extension by a cervical collar or by other strategies dictated by trauma service protocols.
If the patient is hemodynamically unstable, consider alternate positions but never place the adequacy of airway and breathing at risk. When the patient has inadequate circulation, consider placing the patient flat with the legs raised if airway and breathing are adequate (usually when the patient is intubated and on mechanical ventilation). Trendelenburg’s position is not recommended because it may increase the systemic vascular resistance and decrease the cardiac output in some patients, interfere with chest excursion by pushing the abdominal contents upward, and increase the risk of aspiration.
Establish adequate communication. The patient is likely to be very anxious, even fearful, for several reasons. If the hemothorax is the result of a chest trauma, the injury itself is unexpected and possibly quite frightening. The patient is experiencing pain and may not be receiving sedatives or analgesics until the pulmonary status stabilizes. The patient may have low oxygen levels, which leads to restlessness and anxiety. Remain with the patient at all times and reassure him or her until ABCs have been stabilized.
Evidence-Based Practice and Health Policy
Chen, C.Y., Hsu, C.L., Chang, C.H., Chen, K.Y., Yu, C.J., & Yang, P.C. (2010). Hemothorax in a medical intensive care unit: Incidence, comorbidity and prognostic factors. Journal of the Formosan Medical Association, 109(8), 574–581.
- A retrospective review of 6,746 admissions to an intensive care unit (ICU) revealed 53 incident cases of hemothorax (0.79%), 75.5% of which were procedure related (thoracentesis and chest tube thoracostomy were the most common).
- The majority of patients were admitted to the ICU for septic shock (45.3%) or respiratory failure (39.6%), with chronic kidney disease being the most common comorbidity (77.4%).
- Twenty-eight day mortality occurred in 35.8% of the patients. International normalized ratio (INR) was significantly lower (mean of 1.33 versus 2.16; p = 0.018) along with decreases in hemoglobin (mean decrease of 2.36 g/dL versus 3.53 g/dL; p = 0.019) among patients who survived compared to patients who did not.
- Physical findings: Patency of airway, presence of clear breath sounds, vital signs, level of consciousness, urinary output, capillary blanch, skin temperature
- Response to pain: Location, description, duration, response to interventions
- Response to treatment: Chest tube insertion—type and amount of drainage, presence of air leak, presence or absence of crepitus, amount of suction, presence of clots, response to fluid resuscitation; response to surgical management
- Complications: Hemorrhage (ongoing bleeding), infection (fever, wound drainage), inadequate gas exchange (restlessness, dropping SaO2)
Discharge and home healthcare guidelines
Be sure the patient and family understand any pain medication prescribed, including dosage, route, action, and side effects. Review with the patient all follow-up appointments that are arranged. Follow-up often involves chest x-rays and arterial blood gas analysis, as well as a physical examination. If the injury was alcohol related, explore the patient’s drinking pattern. If the injury was binge related, explain the relationship between injury and alcohol by stating the facts without being judgmental. If you think the patient is either a problem or a dependent drinker, refer her or him to an advanced practice nurse or an alcohol counselor. Teach the patient when to notify the physician for complications such as signs of infection, an unhealed wound, or anxiety and inability to cope. Provide the patient with a phone number for a primary healthcare provider, trauma clinic, or advanced practice nurse.