haemothorax

血胸

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2016/06/09 06:26:26」(JST)

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Hemothorax
Classification and external resources
Specialty	emergency medicine
ICD-10	J94.2, S27.1
ICD-9-CM	511.8, 860
DiseasesDB	19762
MedlinePlus	000126
eMedicine	med/2915 ped/971
MeSH	D006491

Hemothorax in an animal

A hemothorax (hemo- + thorax) (or haemothorax/Haemorrhagic pleural effusion) is a type of pleural effusion in which blood accumulates in the pleural cavity. This excess fluid can interfere with normal breathing by limiting the expansion of the lungs.

Signs and symptoms

Hemothorax tends to occur following blunt or penetrating trauma to the thorax or thoracoabdominal area. It may also follow thoracic surgery, or may be spontaneous. Chest pain, dyspnea, and tachypnea are common presenting features. Other symptoms of hemothorax are dependent on the mechanism of injury, but may include:

• Cyanosis
• Decreased or absent breath sounds on affected side
• Tracheal deviation to unaffected side
• Dull resonance on percussion
• Unequal chest rise
• Tachycardia
• Hypotension
• Pale, cool, clammy skin
• Possible subcutaneous emphysema
• Narrowing pulse pressure

Cause and presentation

Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs. This rupture allows blood to spill into the pleural space, equalizing the pressures between it and the lungs. Blood loss may be massive in people with these conditions, as each side of the thorax can hold 30 to 40% of a person's blood volume. Even minor injury to the chest wall can lead to significant hemothorax.

Less frequently, hemothorax occurs spontaneously. A major vascular cause of hemothorax is aortic dissection or rupture of thoracic aortic aneurysms. It may also follow surgical intervention in the thoracic area. Infrequently, patients with pneumothorax may develop spontaneous hemothorax. Spontaneous hemothorax or hemopneumothorax may be occur with endometriosis, if endometrial tissue implants on the pleural surface, then bleeds in response to cyclical hormonal changes in menstruating women.

Mechanism

The thoracic cavity is a chamber within the chest, containing the lungs, heart, and numerous major blood vessels. The parietal pleura lines the chest wall, while the visceral pleura covers the outside of the lungs. The visceral and parietal pleura are separated by a thin layer serous fluid. When a hemothorax occurs, blood enters the pleural cavity, which normally only contains a small amount of pleural fluid. As blood builds up within the pleural cavity, it begins to interfere with the normal movement of the lungs, resulting in dypsnea, poor ventilation, and abnormal oxygenation.

As a result of the body's response to the presence of blood in the pleura, a small hemothorax may lead to a bloody pleural effusion. When enzymes in the pleural fluid begin to break down blood clots, the protein concentration of the pleural fluid increases, and as a result the osmotic pressure of the pleural cavity increases, causing fluid to flow into the pleural cavity from the surrounding tissues. The resulting increase in fluid volume in the pleural cavity interferes with normal breathing and oxygenation, resulting in dypsnea and tachypnea.

Diagnosis

Chest radiography is the preferred means of initial diagnosis for hemothorax. Upright radiography is preferred but supine films may be taken when upright radiography is not feasible due to the clinical situation. Tube thoracostomy may be done prior to imaging when patients have sustained blunt or penetrating thoracic trauma and display unstable hemodynamics, have respiratory failure with absent or decreased breath sounds, show tracheal deviation, or have serious penetrating injuries. In upright radiography, hemothorax is suggested by blunting of the costophrenic angle or partial or complete opacification of the hemithorax, in which the lateral side of the chest appears bright and the lung appears pushed away toward the center; the air-filled lung normally appears as a dark space on radiographic film. In the case of a small hemothorax, several hundred milliliters of blood can be hidden by the diaphragm and abdominal viscera. In supine patients, signs of hemothorax may also be subtle on radiographic film, because the blood will layer in the pleural space, and can be seen as a haziness in one half of the thorax relative to the other side.

Ultrasonography is also used for detection of hemothorax and other pleural effusions, particularly in the critical care and trauma settings, because it provides rapid, reliable results in order to make a diagnosis in an emergency situation. Computed tomography (CT or CAT) scans can detect much smaller amounts of fluid than chest radiography, but computed tomography is not a primary method of diagnosis with in the trauma setting, due to the time required for imaging, the requirement that a patient remain supine, and the need to transport a critically ill patient to the scanner.

Prognosis

If left untreated, the condition can progress to a point where the blood accumulation begins to put pressure on the mediastinum and the trachea, effectively limiting the amount that the heart's ventricles are able to fill. The condition can cause the trachea to deviate, or move, toward the unaffected side.

Management

A hemothorax is managed by removing the source of bleeding and by draining the blood already in the thoracic cavity. Blood in the cavity can be removed by inserting a drain (chest tube) in a procedure called a tube thoracostomy. Generally, the thoracostomy tube is placed between the ribs in the sixth or seventh intercostal space at the mid-axillary line. Usually the lung will expand and the bleeding will stop after a chest tube is inserted.

The blood in the chest can thicken as the clotting cascade is activated when the blood leaves the blood vessels and comes into contact with the pleural surface, injured lung or chest wall, or with the chest tube. As the blood thickens, it can clot in the pleural space (leading to a retained hemothorax) or within the chest tube, leading to chest tube clogging or occlusion. Chest tube clogging or occlusion can lead to worse outcomes as it prevents adequate drainage of the pleural space, contributing to the problem of retained hemothorax. In this case, patients can be hypoxic, short of breath, or in some cases, the retained hemothorax can become infected (empyema).

Retained hemothorax occurs when blood remains in the pleural space, and is a risk factor for the development of complications, including the accumulation of pus in the pleural space and fibrothorax. It is treated by inserting a second chest tube or by drainage by video-assisted thoracoscopy. Fibrolytic therapy has also been studied as a treatment.

When hemothorax is treated with a chest tube, it is important that it maintain its function so that the blood cannot clot in the chest or the tube. If clogging occurs, internal chest tube clearing can be performed using an open or closed technique. Manual manipulation, which may also be called milking, stripping, or tapping, of chest tubes is commonly performed to maintain an open tube, but no conclusive evidence has demonstrated that any of these techniques are more effective than the others, or that they improve chest tube drainage.

In some cases bleeding continues and surgery is necessary to stop the source of bleeding. For example, if the hemothorax was caused by aortic rupture in high energy trauma, surgical intervention is mandatory.

See also

• Cardiac tamponade
• Hemopneumothorax
• Pleural effusion
• Pneumothorax
• Tension pneumothorax
• Pulmonary contusion

References

UpToDate Contents

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• 1. 成人における鈍的胸部外傷の初期評価およびマネージメント initial evaluation and management of blunt thoracic trauma in adults
• 2. 成人における胸水の診断的評価：初期検査 diagnostic evaluation of a pleural effusion in adults initial testing
• 3. 胸腔ドレーンの留置およびマネージメント placement and management of thoracostomy tubes
• 4. 成人における胸壁外傷の初期評価およびマネージメント initial evaluation and management of chest wall trauma in adults
• 5. 外傷性肋骨骨折の入院マネージメント inpatient management of traumatic rib fractures

English Journal

• Hemothorax: etiology, diagnosis, and management.

• Broderick SR.SourceDivision of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Campus Box 8234, 660 South Euclid Avenue, St Louis, MO 63110, USA. Electronic address: brodericks@wudosis.wustl.edu.
• Thoracic surgery clinics.Thorac Surg Clin.2013 Feb;23(1):89-96. doi: 10.1016/j.thorsurg.2012.10.003. Epub 2012 Nov 3.
• Most cases of hemothorax are related to blunt or penetrating chest trauma. Criteria for surgical intervention for initial hemothorax are well defined. Appropriate management of retained hemothorax following initial trauma management is critical, and the best approach remains controversial. Spontaneo
• PMID 23206720

• Large-bore and small-bore chest tubes: types, function, and placement.

• Cooke DT, David EA.SourceDivision of Cardiothoracic Surgery, University of California Davis Medical Center, 2221 Stockton Boulevard, Suite 2117, Sacramento, CA 95817, USA. Electronic address: david.cooke@ucdavis.ucdmc.edu.
• Thoracic surgery clinics.Thorac Surg Clin.2013 Feb;23(1):17-24. doi: 10.1016/j.thorsurg.2012.10.006.
• Chest tubes are placed in the pleural space, either surgically or percutaneously to evacuate abnormal fluid and air. Indications for chest tubes include therapeutic drainage of pleural conditions such as pneumothorax, hemothorax, empyema, chylothorax, and malignant effusions, as well as prophylaxis
• PMID 23206714

Japanese Journal

• Emergency ultrasound in the acute assessment of haemothorax

• BROOKS A
• Emerg Med J 21(1), 44-46, 2004
• NAID 30021668418

• The diagnostic problem associated with blunt traumatic azygous vein injury : delayed appearance of right haemothorax after blunt chest trauma

• SUGIMOTO K.
• Injury 29, 380-382, 1998
• NAID 30002657167

• Haemothorax due to hepatocellular carcinoma rupture successfully controlled by transcatheter arterial embolization

• MASUMOTO A.
• J Gastroenterol Hepatol 12, 156-158, 1997
• NAID 30035640617

Related Links

• Hemothorax: Background, Anatomy, Pathophysiology

Hemothorax is the presence of blood in the pleural space. The source of blood may be the chest wall, lung parenchyma, heart, or great vessels. ... By far the most common cause of hemothorax is trauma. Penetrating ...

• Trauma.org | Haemothorax

The classic signs of a haemothorax are decreased chest expansion, dullness to percussion and reduced breath sounds in the affected hemithorax. There is no mediastinal or tracheal deviation unless there is a massive ...

Related Pictures

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★リンクテーブル★

リンク元

「血胸」

「血胸」

　　[★]

英

hemothorax, hematothorax

ラ

haemothorax

関

気胸、血気胸、緊張性血胸、自然血胸

概念

• 胸膜腔へ血液が貯留した状態をいう。

外傷性血胸の管理

• 出血源をまず気にするように。大動脈、胸郭、肺。
• 胸腔内ドレーンによって肺の再膨張をはかり、出血量の測定を行う。
• 出血量が200ml/hrを越える場合には試験開胸を考慮する。
• 穿通あるいは鈍的外傷により生じる

(Modern Management of Traumatic Hemothorax)

• 管理アルゴリズム

• 1. 臨床的に不安定　→　ATLSガイドラインに従う。開胸術の適応は以下の通り

• 初期アセスメントで1500mlの血性胸水、あるいは3時間の経過で250ml/hrの出血が持続する。 →VATSでも
• 巨大な凝血塊を伴う血胸
• 心タンポナーデの発症
• 胸壁欠損
• ドレナージにもかかわらず重度のエアリークを認める、あるいは肺拡張が不十分な場合
• 大血管損傷
• 食道損傷
• 横隔膜損傷
• 心臓損傷(外傷性の中隔損傷あるいは弁膜損傷

• 2. 臨床的に安定：血液検査(血算、凝固など)、起座位でのエコー検査、胸部CT

• 2-1 血液の貯留が少量の場合(300ml未満)

• 疼痛コントロール、6時間後、24時間後に胸部レントゲン

• 2-2 血性胸水が300mlを越えて貯留している場合

• 胸腔ドレナージの適応
• 2-2-1. (安定：1500ml/24hr未満、250ml/3h未満)胸腔ドレーン留置、VATS、開胸術
• 2-2-2. (不安定：1500ml/24hr超、250ml/3h超)VATS、開胸術

病因

• 特発性血胸
• 外傷性血胸：鈍的外傷、鋭的外傷
• 非外傷性血胸：悪性腫瘍、肺梗塞、結核、感染症(デング出血熱)、肺動静脈瘻、大動脈瘤
• 医原性血胸：胸部外科手術、肺生検、胸膜穿刺