Hemothorax

Hemothorax, an accumulation of blood in the pleural space, affects oxygenation, ventilation, and hemodynamic stability. Approximately 60% of people who experience multiple trauma have chest injuries, and experts estimate that approximately 300,000 cases of trauma-related hemothorax occur each year. 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, atelectasis, intrathoracic hematoma, wound infection, pneumonia, sepsis, 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.

Causes ⬆ ⬇

Approximately 150,000 people die in the United States each year from trauma, and most are caused by blunt trauma from motor vehicle crashes (MVCs), assaults, and falls or by penetrating trauma from knives or gunshot wound. All of these injuries can cause a hemothorax. MVCs cause 70% of chest trauma, and one of every four patients with chest trauma has a hemothorax. Other causes of hemothorax include thoracic surgery, pulmonary infarction, dissecting thoracic aneurysms, tumors, tuberculosis, and anticoagulant therapy.

Genetic Considerations ⬆ ⬇

Hemothorax may occur more commonly in people with clotting or bleeding disorders.

Sex 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. Penetrating injuries from gunshot wounds and stab wounds, which are on the increase in U.S. preteens, teens, and young adults, are more common in males than females. In urban areas, drive-by shootings are increasing, and in some cities, they are associated with half of all youth gunshot wounds. Males have different patterns of injury than females and a higher injury severity. Analysis of trauma outcomes indicates that, following traumatic injury, males have higher rates of multiple organ failure, pneumonia, and sepsis than females, creating health disparities for men (Marcolini et al., 2019). Trauma is the third leading cause of death in people 45 to 65 years old and the seventh leading cause of death in people older than age 65 years. Because they often have fewer compensatory mechanisms to respond to the injury, older adults with such an injury have higher rates of complications and death.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Many types of injuries lead to hemothorax, and injury rates vary by group. In the United States, Black youth ages 15 to 24 years have the highest homicide rate from gunshot wounds, followed by Hispanic youth. Suicide rates are highest among Native American males and non-Hispanic White males. Penetrating injuries from gunshot wounds and stab wounds are more common in non-Hispanic Black persons than in non-Hispanic White persons. Non-Hispanic Black males have adjusted firearm death rates from two to seven times higher than males of other groups. Healthy People 2020 reports that non-Hispanic Black persons have the highest injury death rate in the United States (79.9 injury deaths per 100,000 people), followed by non-Hispanic White people (79.2), Native American people (78.2), Hispanic people (45.5), and Asian/Pacific Islander people (25.6). Geographic information system mapping has shown that impoverished neighborhoods have a higher incidence of gunshot injury than other neighborhoods (Bayouth et al., 2019). Socioeconomic status and injury are linked, with people living with lower incomes having higher risk. Children under 14 years of age living in rural areas have higher rates of unintentional firearm injuries than urban children have. Recent work has shown evidence that rural populations have injury mortality rates that are more than twice as high as urban rates. Many factors contribute to these health disparities, including the distance from major trauma centers. Sexual and gender minority persons have high risk for dating and interpersonal violence, violence related to bullying, and intentional and unintentional injury (Healthy People 2020).

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, injury accounts for 9% of global mortality. 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.

Assessment ⬆ ⬇

ASSESSMENT

History

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. Determine if the patient has a history of alcohol or substance use and abuse both at the time of injury and daily. Establish a history of pulmonary infarction, dissecting thoracic aneurysm, or tumor.

Physical Examination

The most common symptoms are chest pain, tachypnea, and dyspnea, but symptoms may be subtle or 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 (ABCs) 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. Physical findings are best determined when the patient is sitting upright if the patient's condition allows. 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. Note that a delayed hemothorax may occur hours to days after the initial injury from a rupture of a chest wall hematoma or displacement of a fractured rib.

Psychosocial

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 and refer for counseling if appropriate.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Chest x-rays, upright	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: 3.6–5.8 million/mcL; hemoglobin: 11.7–17.4 g/dL; hematocrit: 33%–52%; white blood cells: 4,500–11,100/mcL; platelets: 150,000–450,000/mcL	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 (CT)	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: 80–95 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/needle aspiration, cervical spine x-rays

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisIneffective airway clearance related to airway obstruction as evidenced by stridor, hoarseness, cough, air hunger, restlessness, confusion, and/or dyspnea

Outcomes

OutcomesRespiratory status: Airway patency; Respiratory status: Ventilation; Respiratory status: Gas exchange; Vital signs; Symptom control; Medication response; Mechanical ventilation response: Adult

Interventions

InterventionsAirway management; Airway insertion and stabilization; Airway suctioning; Artificial airway management; Oxygen therapy; Respiratory monitoring; Ventilation assistance; Vital signs monitoring

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

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. Because pneumothorax also occurs with hemothorax, emergency care usually includes needle decompression if tension pneumothorax is suspected. Mild cases of hemothorax may resolve in 10 days to 2 weeks, requiring only observation for further bleeding. 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 1,000 mL that does not continue to bleed can be managed with a chest tube alone. 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 operative procedure.

More severe cases of hemothorax (hemorrhaging that arises from arterial sites or major hilar vessels) generally require aggressive surgical intervention. A massive hemothorax with an initial volume of 1,000 to 2,000 mL or one that continues to bleed between 150 and 200 mL per hour after 2 to 4 hours is an indication for a formal thoracotomy. 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.

Pharmacologic Highlights

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 and thereby 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.

Independent

The most critical nursing intervention is maintaining the 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 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 the patient's 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 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 provide reassurance until the ABCs have been stabilized.

Evidence-Based Practice and Health Policy

Gonzalez, G., Robert, C., Petit, L., Biais, M., & Carrié, C. (2021). May the initial CT scan predict the occurrence of delayed hemothorax in blunt chest trauma patients? European Journal of Trauma and Emergency Surgery, 47, 71–78.

The authors assessed the impact of delayed hemothorax on outcomes in patients with blunt chest trauma without life-threatening condition at admission. They aimed to characterize the predictive value of predefined anatomic factors to identify delayed hemothorax. The authors conducted a retrospective study, including all spontaneous breathing patients (N = 109) admitted to an intensive care unit for a blunt chest trauma.
The patients with delayed hemothorax had higher rates of pulmonary infections. Other markers of hemothorax were a posterior location and a displaced rib fracture. At least one displaced rib fracture was more specific for delayed hemothorax than the commonly used threshold of three or more rib fractures. The authors concluded that posterior location and the displacement of at least one rib fracture in the initial CT scan were independent risk factors for predicting the occurrence of delayed hemothorax.

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DRG Information ⬇

Introduction ⬆ ⬇