there is the introduction part of the torso trauma, check out my next ppts for further more about torso trauma. contents are in following order... introduction mechanism of injury junctional zones of torso tension pneumothorax cardiac temponade massive hemothorax etc. check out all slides

1. MASSIVE
HEMOTHORAX
NAME - DEEPIKA KOMA DEPARTMENT OF SURGERY
ROLL NO. - 28 LBRK GMC JAGDALPUR
BATCH - 2018
MBBS FINAL YEAR PART ll

2. CONTENTS
➢ INTRODUCTION
➢ ETIOLOGY AND RISK
FACTORS
➢ PATHOGENESIS
➢ CLINICAL FEATURES
○ EPIDEMIOLOGY
○ SYMPTOMS
○ SIGN
○ COMPLICATIONS
○ PROGNOSIS
➢ MANAGEMENT
○ ICT
○ IMAGING STUDIES
○ TREATMENT
➢ BIBLIOGRAPHY

3. INTRODUCTION
Rapid accumulation of greater than 1500 ml or 1/3rd blood
volume in Pleural cavity.
A massive hemothorax is defined as blood drainage ≥1500
ml after closed thoracostomy and continuous bleeding at
200 ml/ hour for at least 3 to 4 hours.

4. ETIOLOGY AND RISK FACTORS
1. Traumatic hemothorax
2. Iatrogenic hemothorax
3. Spontaneous/disease complication
hemothorax

5. 1. Traumatic hemothorax (Usually from blunt
trauma or penetrating trauma resulting in
vascular injuries to):
● Chest wall and associated structures,
● Blood vessels, and
● Lung (rare)

6. In blunt injury
1. Continuing bleeding from torn intercostal vessels or
2. Occasionally from the internal mammary artery and,
3. Secondary to fractures of the ribs
CHEST WALL AND ASSOCIATED STRUCTURES

7. In penetrating injury
A variety of viscera, both thoracic and abdominal (with
blood leaking through a hole in the diaphragm from
the positive pressure abdomen into the negative
pressure thorax) may be involved.

8. BLOOD VESSELS
● Aorta and brachiocephalic Arteries
● SVC, IVC, brachiocephalic veins
● Pulmonary arteries and veins
LUNG
● Lung parenchymal injury
● low pulmonary arterial pressure + compressing effect of
blood in pleural space limit bleeding

9. 2. Iatrogenic hemothorax
Central venous catheterization or thoracostomy tube
placement
3. Spontaneous/disease complications
Tuberculosis, pulmonary embolism, Coagulopathy,
neoplasia, thoracic aortic dissection or aneurysm
LESS COMMON ETIOLOGIES

10. Trauma to the thoracic cavity leads to bleeding and subsequent
blood pooling in the pleural cavity
PATHOGENESIS
interferes with normal movement of the lungs by preventing
normal expansion of the lungs

11. ● Mainly altered cardiac and respiratory functions
● Influenced by amount and rate of blood loss
● Large clots in pleural space release fibrinolysins leading to
further bleeding
● Residual hemothorax increases osmotic pressure
● Leads to fluid transudation and increases pleural fluid
volume
Cont…

12. ● Each hemithorax can hold 40-
50% of circulating blood
volume
● Blood can accumulate rapidly
in pleural space
● Decreases preload
● Compromises LV function and
cardiac output
LIFE-THREATENING BY 3
MECHANISMS
● Compresses venacava
○ Decreases preload
● Compresses lung parenchyma
○ Increases vascular
resistance
● From lung collapse
● alveolar hypoventilation
ACUTE HYPOVOLEMIA HYPOXIA PRESSURE OF HEMOTHORAX

13. ● Motor vehicle collisions (MVCs) represents the most
common cause of major thoracic injuries.
● Hemothorax related to trauma around 300,000
cases/year
● 60-70% in blunt chest trauma
● 50-60% in penetrating trauma
● Incidence of hemothorax and pneumothorax increases
with number of ribs fracture
EPIDEMIOLOGY
INCIDENCE/PREVALENCE

14. ● Rapid, shallow breathing
● Dypnea
● Pleuritic Chest pain
● Low blood pressure (hypovolaemic shock)
● Pale, cool and clammy skin
● Rapid heart rate
● Restlessness
● Anxiety
SYMPTOMS

15. INSPECTION: asymmetrical Chest movement with
respiration (at the affected side) , flat neck veins
PALPATION: Tenderness, trachea might be shifted (if
massive bleeding causes mediastinal shift)
PERCUSSION: dullness at the Affected side
AUSCULTATION: decreased or absent breath sound
SIGNS

16. Signs and
symptoms of
massive
hemothorax

17. DO NOT DELAY
treatment for imaging
study.

18. Management of massive hemothorax
Volume
Replacement
Chest
decompression
Correcting the
hypovolaemic shock
Insertion of an
intercostal drain

19. INTERCOSTAL CHEST TUBE INSERTION(ICT)
Indication : Pneumothorax, hemothorax, pleural effusion
Size of ICT - Large bore 24 - 36 F
SITE - ICS 4th or 5th at mid axillary line
Triangle of safety

20. TUBE THORACOSTOMY

21. CHEST X RAY (bedside)
Portable supine
● May show only general
haziness or opacification of
affected lung field, even
with 1 L of blood in
hemithorax
● Look for rib fractures
● May see tracheal deviation
Upright (best for primary
imaging)
● Blunting of costophrenic
angle equate to 400-500 mL
of blood
● Air-fluid interface seen if
hemopneumothorax.

22. CHEST X RAY FINDINGS

23. Ultrasound (bedside)
● Use as part of FAST and as adjunct with
CXR
● Shows fluid between chest wall and lung for
hemothorax
● With penetrating trauma, provides info on
pericardial involvement
● Greater sensitivity and equal specificity
than CXR

24. CT SCAN
● Use if CXR ambiguous or initial treatment
fails
● Highest sensitivity and specificity for
hemothorax
● More sensitive for localization of clots,
loculated collections

25. TREATMENT

27. COMPLICATIONS
● Clot retention (3%)
● Pleural infection (3-4%)
● Pleural effusion(13-34%)
● Empyema(5%)
● Fibrothorax(1%)
● Complications of tube thoracostomy (25 - 30% overall complications)
○ Improper tube placement
○ Pneumothorax
○ Re-expansion pulmonary edema
○ Spleen or liver puncture
○ Infection

28. PROGNOSIS
Mortality/Morbidity
Thoracic injuries responsible for 20-25% of all trauma-related deaths
15% of those with chest trauma need thoracotomy
Risk factors for mortality among blunt trauma patients
● Age > 64 years old
● > 2 rib fractures
Pre-existing disease, especially cardiopulmonary.

29. DIFFERENTIAL DIAGNOSIS
● Pneumothorax
● Tension pneumothorax
● Cardiac temponade
● Pulmonary laceration
● Tracheal / Bronchial injuries
● Non-aortic vascular trauma
● Traumatic aortic rupture
● Penetrating cardiac injuries

30. BIBLIOGRAPHY
Bailey and love’s short practice of surgery
SRB’s mannual of surgery

31. Thank you