Image of the Day 5: Left Hemothorax Muhamad Na’im B. Ab Razak (MD USM)This unfortunate young man was brought to the emergency department after involve in motorvehicle accident (Motorbike vs lorry) where his body smashed against the lorry. He sustainsloss of consciousness for about 5 minutes, retrograde amnesia, chest pain and shortness ofbreath. This is the chest x ray of the patient which shows opacity of the left hemithorax upto the upper zone with obliteration of costophrenic angle. The trachea is shifted to theright. After further evaluation, a diagnosis of Cerebral Concussion with left hemothoraxwas made and chest tube was inserted.
In this section, i will briefly discussed about hemothorax. Bear in minds that hemothorax canbe a life threatening or the lethal one for the patient. Small hemothorax sometimes leftundiagnosed and patient was discharged home with sequale of progressive on going bleeding.As in this case, blunt trauma is one of the causes for hemothorax. Others would be penetratingchest trauma, iatrogenic and spontaneous.As a general rule, if hemothorax is obscuring the costophrenic sulcus or associated withpneumothorax, therefore it should be drained via chest tube. In case of massive hemothorax;1) More than 1000 cc blood drained post insertion of chest tube, 2) more than 150-200 ml/hrblood drained for 2-4 hours, 3) Requirement of repeated blood transfusion to maintainhemodynamic stability, surgical intervention would be needed.Other measure needed in resuscitating this patient includes, 1) evaluation of airway patency,2) two large bore IV access preferably in the ante cubital fossa, 3) Strict I/O monitoring, 4)Folley’s catheter insertion, 5) GXM of at least 3 pints packed cells, 6) Reserve a GSH as wemay need to convert to whole blood and DIVC regimes later depending on patient condition.7) Monitoring of vital sign, blood parameter, baseline ECG, 8) Insertion of Central venousline if required intensive monitoring, 9) KIV for intubation if patient condition deteriorated,10) Fluid resuscitation and maintenance. Do not use crystalloid containing dextrose even formaintanance as this patient having cerebral concussion, 11) Evaluation of other systemicinjury and finally 12) To treat any associated injury (Due to trauma or any metabolicderangement due to hemothorax)Sequale of hemothorax including residual clot, infected collections, and trapped lung due tofibrothorax or empyema.Reference:1. Hemothorax by Mary C. Mancinihttp://emedicine.medscape.com/article/2047916Accessed on 21 April 2012, 1.30 pm