Hemothorax percussion sound. Hemothorax: symptoms, classification and treatment. Conservative therapy is aimed at

Hemothorax is diagnosed when blood collects in the chest as a result of injury or other factors.

The accumulation of blood occurs between the chest wall and the lung.

Hemothorax can have multiple causes, and the wide range of symptoms helps doctors quickly identify and treat the condition.

The most common cause of hemothorax is traumatic injury to the chest, such as puncture wounds from broken ribs or blunt injuries from car accidents.

As hemothorax progresses, people may experience different symptoms. When diagnosing this condition, doctors typically perform a physical examination and imaging tests.

Treatment involves stabilizing the patient if he has been injured, removing all blood from the chest, and eliminating the source of bleeding.

The content of the article:

Fast facts about hemothorax

1. Hemothorax is the result of extrapleural or intrapleural injuries.
2. Extrapleural injuries are caused by damage to the tissues of the chest wall on the outside of the pleural cavity. Intrapleural injury is damage to the inside of the pleural cavity.
3. Hemothorax often develops along with, that is, the accumulation of air in the pleural cavity.
4. Symptoms of hemothorax include chest pain and rapid heartbeat.
5. Treatment involves inserting a catheter between the ribs to drain blood and remove air.

The reasons

In hemothorax, blood collects in the space between the chest wall and the lung. This space in medicine is called the pleural cavity. Below are the reasons why blood can get there.

traumatic injury

Traumatic chest injury is the most common cause of hemothorax

Traumatic hemothorax is often caused by a puncture of the pleural membrane that separates the lung from the chest. A puncture of the membrane leads to the entry of blood into the pleural cavity, which has no way out.

Even minor damage to the chest wall or lungs can lead to hemothorax.

In emergency care centers, standard diagnostic procedures after car accidents, sports injuries, or other incidents include examining the patient's lungs for signs of hemothorax.

Other reasons

In addition to injuries, other problems can lead to hemothorax. Some people have an increased risk of developing hemothorax. The degree of risk often depends on the presence of certain medical conditions.

Such a hemothorax is called spontaneous. It can affect people with the following conditions:

• lung infections, such as tuberculosis;
• certain types of cancer, such as lung or pleural cancer;
• pulmonary embolism, that is, a blood clot in the lungs;
• abnormalities in blood clotting, for example, in connection with the use of anticoagulants or with hemophilia;
• dysfunction of the lung tissue, for example, with a pulmonary infarction;
• damage to blood vessels in the lungs.

Hemothorax can also result from medical procedures, such as heart surgery or a catheter inserted into a vein. In more rare cases, hemothorax develops suddenly for no apparent reason.

Another common problem arising from traumatic injuries of the chest is pneumothorax, which is characterized by the accumulation of air in the pleural cavity. If the patient's pleural cavity contains both blood and air, then this condition is commonly called hemopneumothorax.

Symptoms

Hemothorax causes some unique symptoms. This helps both doctors and patients to identify the condition. Symptoms of hemothorax include the following:

• chest pain, especially when inhaling;
• cold, pale, or clammy skin;
• high heart rate;
• low blood pressure;
• strained, fast, or shallow breathing;
• labored breathing;
• restlessness;
• anxiety.

Massive hemothorax is a condition in which a significant volume of blood accumulates in the chest (at least 1000 milliliters). This hemothorax can lead to shock.

People with pneumothorax or other related disorders may experience additional symptoms.

Diagnostics

Hemothorax is diagnosed by x-ray or computed tomography

During a physical examination, doctors use a stethoscope to listen to the patient's lungs, looking for abnormalities in breathing.

Other diagnostic procedures include the following.

• X-ray examination. A chest x-ray can quickly tell if there is fluid in the chest cavity. On x-rays, the lungs are black, and the fluid in the pleural space stands out against this dark background with a white tint.
• CT scan. This procedure provides the clinician with a detailed view of the lungs and pleural cavity, which can be especially important when diagnosing injuries. A complete chest CT scan often allows doctors to find out the cause of a hemothorax and prescribe the best treatment for the patient.
• Ultrasound procedure. In the emergency medical setting, ultrasound provides the ability to quickly and accurately see potential damage to the pleural cavity and detect hemothorax.

To make a diagnosis, a doctor may take a sample of pleural fluid. If the patient has a hemothorax, then this sample will contain blood.

Treatment

The doctor will take several steps for successful treatment.

First of all, he will insert a needle or catheter into the chest through the ribs. With this needle, blood and air will be removed from the pleural cavity.

Except in a medical emergency, the doctor will use sedatives and pain medication before inserting the catheter.

After draining, the doctor may use the same tube to expand the affected lung if collapse is observed.

The tube remains attached to a closed system that allows air and fluid to escape but prevents new air from entering the pleural space.

To get rid of hemothorax, treatment should be directed to its cause. In cases with minor injuries, chest drainage may be sufficient, but in severe injuries, patients sometimes require surgery to stop bleeding by removing its cause.

Risk factors

Complicated heart and lung surgery may increase risk of hemothorax

Hemothorax usually results from accidents or other traumatic injuries that are difficult to prevent. There are other risk factors, which include the following.

• Operation. Some complex surgical procedures, such as open-heart surgery or a lung transplant, put people at increased risk of developing hemothorax. After such surgical interventions, doctors usually monitor the patient's condition in time to see any signs of blood accumulation in the lung area.
• Repetitive injury. Hemothorax can be caused by blunt or blunt injuries sustained during athletic training such as boxing or mixed martial arts. People who participate in these or other contact sports are at increased risk of injury from thuds to the chest, abdomen, or shoulders.

Complications

Hemothorax can cause complications. The most common of these include the following.

• Lung problems. Blood pressure in the chest can cause the lung to collapse. If the condition progresses, it can lead to respiratory failure.
• Infections. If left untreated, hemothorax can cause infections of the lungs, pleura, or pleural fluid in the chest cavity.
• Scarring. Pleural membranes and lung tissues with hemothorax are more prone to scarring. Over time, this can lead to fibrosis and immobilization of the ribs.

Complications may require additional surgery or other medical care. In severe cases, hemothorax can lead to shock and subsequent death.

Coagulated hemothorax

Clotted hemothorax is a complication that occurs when blood stays in the pleural space for too long. Blood in such situations can clot, which makes it difficult for medical personnel to remove it through the catheter. Blood that remains in the chest for a long period of time can cause pus to develop in nearby areas, and this often leads to infection.

Clotted hemothorax is treated by inserting other tubes into the pleural cavity for subsequent drainage. In addition, doctors in such cases perform video-assisted operations.

Treatment prospects

Hemothorax is a serious medical condition that can be life-threatening if left untreated. When a person receives timely medical attention, the outlook for hemothorax treatment is usually good.

Without the help of doctors, the variant of a lethal outcome is not excluded. Therefore, anyone who has experienced chest trauma should be tested for hemothorax. Symptoms of hemothorax require immediate medical attention. During emergency treatment, doctors can reduce the risk of serious complications.

Rehabilitation after hemothorax depends on how well the patient's body responds to treatment and how quickly the blood was removed from the pleural cavity.

- this is bleeding into the pleural cavity, the accumulation of blood between its sheets, leading to compression of the lung and displacement of the mediastinal organs in the opposite direction. With hemothorax, there is pain in the chest, difficulty breathing, signs of acute blood loss develop (dizziness, pallor of the skin, tachycardia, hypotension, cold clammy sweat, fainting). Diagnosis of hemothorax is based on physical data, the results of fluoroscopy and chest radiography, CT, diagnostic pleural puncture. Treatment of hemotrax includes hemostatic, antibacterial, symptomatic therapy; aspiration of accumulated blood (punctures, drainage of the pleural cavity), if necessary, open or video-assisted thoracoscopic removal of clotted hemothorax, stopping ongoing bleeding.

ICD-10

J94.2

General information

Hemothorax is the second most common (after pneumothorax) complication of chest trauma and occurs in 25% of patients with thoracic trauma. Quite often in clinical practice there is a combined pathology - hemopneumothorax. The danger of hemothorax lies both in increasing respiratory failure due to compression of the lung, and in the development of hemorrhagic shock due to acute internal bleeding. In pulmonology and thoracic surgery, hemotrax is regarded as an emergency condition requiring emergency specialized care.

Causes of hemothorax

There are three groups of causes that most often lead to the development of hemothorax: traumatic, pathological and iatrogenic.

• Traumatic causes are understood as penetrating wounds or closed injuries of the chest. Thoracic trauma, accompanied by the development of hemothorax, includes road accidents, gunshot and stab wounds to the chest, fractures of the ribs, falls from a height, etc. With such injuries, damage to the organs of the chest cavity (heart, lungs, diaphragm), abdominal organs (injuries liver, spleen), intercostal vessels, internal thoracic artery, intrathoracic branches of the aorta, the blood from which flows into the pleural cavity.
• The causes of pathological hemothorax include various diseases: lung or pleura cancer, aortic aneurysm, pulmonary tuberculosis, lung abscess, neoplasms of the mediastinum and chest wall, hemorrhagic diathesis, coagulopathy, etc.
• Iatrogenic factors leading to the development of hemothorax are complications of operations on the lungs and pleura, thoracocentesis, drainage of the pleural cavity, catheterization of the central veins.

Pathogenesis

The accumulation of blood in the pleural cavity causes compression of the lung on the side of the lesion and displacement of the mediastinal organs in the opposite direction. This is accompanied by a decrease in the respiratory surface of the lung, the occurrence of respiratory and hemodynamic disorders. Therefore, with hemotrax, a clinic of hemorrhagic and cardiopulmonary shock often develops with acute respiratory and heart failure.

Already in the next few hours after the blood enters the pleural cavity, aseptic inflammation of the pleura develops - hemopleurisy, caused by the reaction of the pleural sheets. With hemothorax, edema and moderate leukocyte infiltration of the pleura, swelling and desquamation of mesothelial cells occur. In the initial period, the blood poured into the pleural cavity practically does not differ in composition from the peripheral blood. In the future, there is a decrease in hemoglobin, a decrease in the erythrocyte-leukocyte index.

Once in the pleural cavity, the blood first coagulates. However, then soon the process of fibrinolysis sets in, and the blood thins again. This is facilitated by anticoagulant factors contained in the blood itself and pleural fluid, as well as mechanical defibrination of blood due to respiratory excursion of the chest. As the anticoagulation mechanisms are depleted, blood coagulation and the formation of a clotted hemothorax occur. In the case of the addition of microbial infection against the background of hemothorax, pleural empyema can occur quite quickly.

Classification

In accordance with the etiology, traumatic, pathological and iatrogenic hemothorax are distinguished. Given the amount of intrapleural bleeding, hemothorax can be:

• small- volume of blood loss up to 500 ml, accumulation of blood in the sinus;
• average- volume up to 1.5 l, blood level to the lower edge of the IV rib;
• subtotal- volume of blood loss up to 2 l, blood level to the lower edge of the II rib;
• total- the volume of blood loss is more than 2 liters, X-ray is characterized by a total darkening of the pleural cavity on the side of the lesion.

The amount of blood flowing into the pleural cavity depends on the location of the injury and the degree of vascular destruction. So, if the peripheral parts of the lung are damaged, in most cases a small or medium hemothorax occurs; when the root of the lung is injured, the main vessels are usually damaged, which is accompanied by massive bleeding and the development of subtotal and total hemothorax.

In addition, a limited (usually small in volume) hemothorax is also isolated, in which the outflow of blood accumulates between the pleural adhesions, in an isolated area of ​​​​the pleural cavity. Taking into account localization, limited hemothorax can be apical, interlobar, paracostal, supradiaphragmatic, paramediastinal.

In the case of ongoing intrapleural bleeding, they speak of an increasing hemothorax, in the event of a cessation of bleeding, they speak of a non-increasing (stable). Complicated types include clotted and infected hemothorax (pyogemothorax). With the simultaneous entry of air and blood into the pleural cavity, they speak of hemopneumothorax.

Symptoms of hemothorax

The clinical symptoms of hemothorax depend on the degree of bleeding, compression of the lung tissue and displacement of the mediastinal organs. With a small hemothorax, clinical manifestations are minimally expressed or absent. The main complaints are chest pain, aggravated by coughing, moderate shortness of breath.

With a hemothorax of medium or large size, respiratory and cardiovascular disorders develop, expressed in varying degrees. Characterized by a sharp pain in the chest, radiating to the shoulder and back when breathing and coughing; general weakness, tachypnea, decreased blood pressure. Even with slight physical exertion, symptoms worsen. The patient usually takes a forced sitting or semi-sitting position.

In severe hemothorax, the clinic of intrapleural bleeding comes to the fore: weakness and dizziness, cold sticky sweat, tachycardia and hypotension, pallor of the skin with a cyanotic tint, flies before the eyes, fainting.

Hemothorax associated with rib fractures is usually accompanied by subcutaneous emphysema, soft tissue hematomas, deformity, pathological mobility and crepitus of rib fragments. With hemothorax that occurs with a rupture of the lung parenchyma, hemoptysis may occur.

In 3-12% of cases, a clotted hemothorax is formed, in which blood clots, fibrin layers and stitches form in the pleural cavity, limiting the respiratory function of the lung, causing the development of sclerotic processes in the lung tissue. The clinic of clotted hemothorax is characterized by heaviness and pain in the chest, shortness of breath. With an infected hemothorax (empyema of the pleura), signs of severe inflammation and intoxication come to the fore: fever, chills, lethargy, etc.

Diagnostics

To make a diagnosis, the details of the history of the disease are specified, a physical, instrumental and laboratory examination is carried out. With hemothorax, the lagging of the affected side of the chest during breathing, dullness of percussion sound above the liquid level, weakening of breathing and voice trembling are determined. X-ray and plain radiography of the lungs revealed collapse of the lung, the presence of a horizontal level of fluid or clots in the pleural cavity, flotation (shift) of the shadow of the mediastinum in a healthy direction.

For diagnostic purposes, a puncture of the pleural cavity is performed: obtaining blood reliably indicates hemothorax. To differentiate sterile and infected hemothorax, Petrov's and Efendiev's tests are carried out with an assessment of the transparency and sediment of the aspirate. In order to judge the cessation or continuation of intrapleural bleeding, a Ruvelua-Gregoire test is performed: clotting of the received blood in a test tube or syringe indicates ongoing bleeding, the absence of coagulation indicates the cessation of bleeding. Punctate samples are sent to the laboratory for hemoglobin determination and bacteriological examination.

With a banal and clotted hemothorax, they resort to the laboratory determination of Hb, the number of erythrocytes, platelets, and the study of a coagulogram. Additional instrumental diagnostics for hemothorax may include ultrasound of the pleural cavity, rib radiography, chest CT, diagnostic thoracoscopy.

Treatment of hemothorax

Patients with hemothorax are hospitalized in specialized surgical departments and are under the supervision of a thoracic surgeon. With a therapeutic purpose for aspiration / evacuation of blood, the pleural cavity is drained with the introduction of antibiotics and antiseptics into the drainage (to prevent infection and sanitation), proteolytic enzymes (to dissolve clots). Conservative treatment of hemothorax includes hemostatic, antiplatelet, symptomatic, immunocorrective, blood transfusion therapy, general antibiotic therapy, oxygen therapy.

Small hemothorax in most cases can be eliminated conservatively. Surgical treatment of hemothorax is indicated in case of ongoing intrapleural bleeding; with clotted hemothorax, preventing the expansion of the lung; damage to vital organs.

In case of injury of large vessels or organs of the chest cavity, an emergency thoracotomy, ligation of the vessel, suturing of the wound of the lung or pericardium, removal of the blood that has flowed into the pleural cavity is performed. Clotted hemothorax is an indication for elective videothoracoscopy or open thoracotomy to remove blood clots and sanitize the pleural cavity. With suppuration of hemothorax, treatment is carried out according to the rules for the management of purulent pleurisy.

Forecast and prevention

The success of hemothorax treatment is determined by the nature of the injury or disease, the intensity of blood loss and the timeliness of surgical care. The prognosis is most favorable for small and medium uninfected hemothorax. Clotted hemothorax increases the likelihood of developing pleural empyema. Continued intrapleural bleeding or simultaneous large blood loss can lead to the death of the patient.

The outcome of hemothorax may be the formation of massive pleural adhesions that limit the mobility of the dome of the diaphragm. Therefore, during the rehabilitation period for patients who have undergone hemothorax, swimming and breathing exercises are recommended. Prevention of hemothorax consists in the prevention of injuries, the obligatory consultation of patients with thoracoabdominal trauma by a surgeon, the control of hemostasis during operations on the lungs and mediastinum, and the careful performance of invasive manipulations.

Hemothorax is an accumulation of blood in the pleural cavity due to a penetrating or non-penetrating injury to the chest. It occurs in 25-60% of patients with chest trauma and is often associated with pneumothorax.

Classification of hemothorax. There are three degrees of hemothorax; first degree - small hemothorax (accumulation of blood in 1/3 of the pleural cavity is filled with blood); the second degree is an average hemothorax (the blood level reaches the lower angle of the scapula, that is, 2/3 of the pleural cavity is filled with blood); third degree - large hemothorax (all or almost the entire pleural cavity is filled with blood).

Symptoms of hemothorax. Manifestations of small hemothorax are minimal: in the area of ​​injury, slight limitation of breathing volume. With an average hemothorax, cough and shortness of breath, more pronounced pain in the chest, and pallor of the skin appear. A large and growing hemothorax is accompanied by signs of internal bleeding: weakness, flies before the eyes, cold sticky sweat, shortness of breath, tachycardia, hypotension. Sometimes hemorrhagic shock develops.

Diagnostics. During a physical examination, a shortening of the percussion sound is found, a weakening of vesicular breathing on the side of the lesion. Chest x-ray shows opacity with a horizontal fluid level in the corresponding hemithorax. In the case of accumulation of blood in the posterior costophrenic sinus, it is detected during polypositional examination. Blood can be evenly distributed over the diaphragm, giving the impression of a high dome. The darkening area changes by its width on the lathetoroscope, and also depending on the act of breathing (Prozorov's symptom): when inhaling, its volume increases due to the expansion of the chest.

In the diagnosis of hemothorax, the pleural cavity is informative.

There are urgent and delayed thoracoscopy for chest trauma. Emergency thoracoscopy is performed within 24 hours of injury. The indications for thoracoscopy are:

1) penetrating wounds of the chest below the VII rib (to exclude the possibility of thoracoabdominal injuries);

2) penetrating wounds of the projection of the heart and large vessels;

3) closed injury of the chest with blood loss of more than 1 liter per day, detected during thoracocentesis or pleural cavity;

4) clotted hemothorax;

Thoracoscopy is contraindicated in: 1) hemorrhagic shock; 2) cardiac tamponade; 3) obliteration of the pleural cavity.

It should be noted that the Ruvelua-Gregoire test can be used to differentiate between hemothorax and ongoing bleeding into the pleural cavity. The essence of the test is that the blood obtained by puncture from the pleural cavity in patients with ongoing bleeding coagulates within 1-3 minutes, and when the bleeding stops, it loses this ability (hemolyzed).

Treatment of hemothorax. Patients with hemothorax are subject to differentiated treatment. In patients without shock, drainage of the pleural cavity is performed (with a small hemothorax - puncture), usually in the 7th or 8th intercostal space along the posterior axillary line, followed by dynamic monitoring of the amount of blood released or accumulating in the pleural cavity against the background of intensive treatment (hemostatic, antishock and other Events). If the amount of blood released is less than 200 ml / h, conservative treatment continues. In case of blood loss of 200 ml/h for 5 hours (300 ml/h for 3 hours), thoracotomy, revision of the pleural cavity and stopping bleeding using one of the existing methods (suturing the wound of the lung, chest wall, lung resection, etc.) are indicated. For treatment (with the exception of a large hemothorax and hemothorax, combined with signs of a heart injury), video thoracoscopy is also used, during which blood is removed from the pleural cavity, bleeding is stopped from ruptures of the lung, chest wall by endoscopic diathermocoagulation, quantum photocoagulation, clipping or flashing of blood vessels. Emergency thoracotomy is performed in patients with hemothorax who are in a state of hypotension, which is not stopped in a short time by intensive conservative measures (compensation of BCC, analgesic therapy, etc.).

Coagulated hemothorax

In 3-12% of victims, trauma to the pleural cavity ends with the formation of a clotted hemothorax. The latter is characterized by the formation of dense blood clots, fibrin layers, moorings in the pleural cavity, which impede the respiratory function of the lung, contributing to the flow of sclerotic processes in it.

Symptoms of a clotted hemothorax. Patients with clotted hemothorax complain of heaviness, pain in the chest on the affected side of varying severity, shortness of breath. Their condition worsens significantly when infected with hemothorax (development of pleural empyema).

Diagnostics. Of primary importance in establishing the presence of a clotted hemothorax are x-ray and ultrasound examinations of the chest, thoracoscopy.

Treatment of clotted hemothorax. Patients with clotted hemothorax are subject to complex treatment against the background of general antibacterial, anti-inflammatory, detoxification, immuno- and antioxidant therapy, and physiotherapy. Hemothorax is punctured at its lowest point, followed by a single (repeated with an interval of 2-3 days) intrapleural administration of proteolytic drugs - terrilitin, trypsin in combination with a wide spectrum of action. As a rule, clots are lysed after 2-3 days. Then a repeated puncture of the pleural cavity is performed, during which the resulting fluid is assimilated, and the pleural cavity is washed with an antiseptic solution. For the treatment of clotted hemothorax, the method of ultrasonic fragmentation of blood clots through a thoracoscope is also used. In case of failure of conservative treatment, when symptoms of suppuration appear, videothoracoscopy or thoracotomy is performed to eliminate the clotted hemothorax.

The article was prepared and edited by: surgeon

Most often it is formed as a complication after injuries of the thoracic region. This condition is associated with damage to the vessels by the constituent elements of the chest, which are in close proximity to the cardiopulmonary complex. The amount of blood lost can vary depending on the degree of damage to the pleura.

With damage to the intercostal arteries massive hemorrhage occurs, such a hemothorax is called extensive. This condition is considered urgent due to the increase in mechanical compression of the pulmonary trunk, a large amount of blood lost and requires urgent surgical intervention. In this case, the syndrome of pulmonary insufficiency is expressed.

The reasons

The development of hemothorax with subsequent accumulation of exudate and the liquid part of the blood in the pleura is preceded by a number of pathologies. These include:

• Mechanical damage to the chest after a gunshot or knife wound.
• Chest trauma.
• Fractures of the skeletal skeleton of the thoracic region.
• Compression fractures.
• Change in the wall of the aorta.
• Rupture of a tuberculous bulla.
• Malignant and benign neoplasms of the trachea, lungs.
• Consequences of chronic obstructive pulmonary disease.
• Blood outcomes of chronic diseases.
• Complications after surgical interventions in the chest.
• Placement of central catheters.
• Destruction of the walls of the bronchial tree.

Classification

Hemothorax is classified according to the degree of bleeding, course, side of the process and attachment of the infectious agent.

Depending on the degree allocate small, medium, subtotal and total degree of bleeding.

• With a small degree of bleeding, the volume of blood loss is not more than 500 ml, an accumulation of exudate in the sinus is noted on the x-ray.
• The average degree is characterized by blood loss ranging from 500 to 1500 ml. On the radiograph, the blood level is determined at the level of the 4th intercostal space.
• With a subtotal degree, blood loss reaches 2000 ml, the fluid level on the radiograph rises to the lower edge of the second rib.
• The total degree is characterized by massive blood loss of more than two liters. On the X-ray, a complete blackout of the affected side is observed.

The hemothorax is divided into clotted, spontaneous, pneumohemothorax, traumatic hemothorax.

• Clotted hemothorax is characterized by the presence of blood clots in the pleural cavity, which are formed after previous coagulation treatment. Most often occurs after surgery.
• With arbitrary bleeding into the pleural cavity, spontaneous hemothorax is formed. This type of disease is extremely rare.
• Pneumohemothorax is characterized by a mixed origin. With this pathology, air and blood are simultaneously in the pleural cavity. The most common cause is a ruptured tubercular bulla.
• A patient with traumatic hemothorax will have a history of trauma or penetrating injury to the chest. An important factor in damage to the pleura will be the rupture of the wall by damaged ribs.

On the side of the lesion is divided into left and right hemothorax.

If the lesion is located in the left lobe of the lung, then it is customary to call it a left-sided hemothorax. With damage to the right lobe of the lung, respectively, right-sided hemothorax. It should be noted that with right-sided hemothorax, the risk of severe consequences for the patient is higher than with left-sided lesions. This is due to the rapid increase in respiratory failure. Bilateral hemothorax affects both lobes of the lungs. This condition is urgent. Action must be taken within one minute.

An infectious agent may join the development of the disease in the first hours. Hemothorax is divided into infected and uninfected.

In dynamics, they are divided into stable and increasing current.

Symptoms

With an unexpressed course of the disease may be asymptomatic. Percutere there is a shortening of the received sound along the posterior axillary line. Auscultatory - a decrease in lung excursion over the lower sections of the lungs.

With a severe degree of hemothorax, symptoms characteristic of internal bleeding appear: it increases, cyanosis of the skin is visible, cold sweat, blanching of the skin, low blood pressure. The patient notes the appearance of pain in the side, shortness of breath.

As the disease progresses, respiratory failure. A dull sound is heard on percussion, mainly over the lower parts of the lungs. Auscultatory - weakening of the lung sound.

Diagnostics

To determine the presence of hemothorax, you can use:

• x-ray;
• ultrasound;
• bronchoscopic examination, which is accompanied by a biopsy;
• cytological examination of sputum;
• performing thoracentesis using Petrov's or Rivillua-Gregoire's samples.

In addition, an effective diagnostic method is pleural puncture, which is also a medical procedure. To conduct this study, a puncture is made in the chest wall, which should reach the pleura. Then, through this hole, using a syringe and suction, the exudate (contents) is removed from the pleural cavity. The procedure turns from diagnostic to therapeutic, because all unwanted fluid that makes it difficult to breathe is removed. Also, additionally through a puncture, you can rinse the cavity, introduce antibiotics and drain.

But the most accurate diagnostic study is considered to be an endoscopic procedure - thoracoscopy. This method makes it possible to see the inner surface of the pleural cavity.

Treatment

If hemothorax is suspected, the patient need to call an ambulance immediately. After all, a non-specialist will not be able to provide qualified assistance with this defeat. Doctors will apply a tight bandage and try to stop the bleeding, as well as mitigate the effects of falling blood levels with infusion solutions. Under the supervision of specialists and constant monitoring of hemodynamics, the patient is hospitalized in the thoracic surgical department.

The further course of treatment will be determined by a thoracic surgeon or pulmonologist. Usually, to eliminate possible complications, it is necessary chest puncture for the study and elimination of exudate. At the same time, a drainage (passive or active) is placed, through which the necessary drugs of proteolytic and bacterial action are administered.

Therapy is not complete without blood substitutes, antiplatelet agents, immunocorrectors, hemostatic and antibacterial agents.

If all of the above measures do not lead to an improvement in the condition, it is necessary surgical procedures videothoracoscopy and open thoracotomy.

Complications

Hemothorax has a number of complications, which include the following:

• Due to the removal of blood from the zone of the pleural cavity, it is possible. This complication is rare. Against the background of it, hypovolemia may develop.
• In case of secondary infection of the blood clot, empyema may develop. This happens as a result of combined lung injuries. It is also possible with damage from external sources (any penetrating objects that became the original cause of injury).
• Fibrothorax and compression of the lungs develops when fibrin precipitates in the clotted mass of blood. This can cause permanent atelectasis and decreased lung function. To reduce the risks of an epidemic, as well as correct the situation with enlarged lungs, a decortication procedure is performed.

Also with hemothorax are diagnosed:

• anemia;
• respiratory failure;

Prevention

The basis of prevention in this case is the prevention of injury. If there have been injuries to the abdomen or chest area, it is necessary to consult a thoracic surgeon. If you had to resort to surgical intervention, the patient needs further constant monitoring of the condition.

Forecast

The prognosis of hemothorax depends on several factors such as:

• complexity of damage to the chest and nearby organs of the victim;
• volumes of blood loss;
• the correctness and timeliness of actions in the provision of first aid.

In addition, the very nature of the damage directly affects the effectiveness of the treatment, in particular, whether the hemorrhage affected one side or two.

A more optimistic prognosis with a small or moderate degree of pathology. If we are talking about a curled form, increased risk of empyema. The most pessimistic scenario awaits patients with the consequences of hemothorax, which are accompanied by prolonged or simultaneous heavy bleeding. Here we can talk about death. The most difficult case to predict is when the consequences of hemothorax are accompanied by large and prolonged bleeding. There is a high chance of death here..

For a favorable prognosis, it is enough for a person with hemothorax to receive timely and competent help, as well as appropriate treatment. During the rehabilitation period, experts advise to go in for sports: swimming, breathing exercises, walking. Especially lung exercises are important, because they prevent the appearance of adhesions in the pleura, which is very important for the functioning of the diaphragmatic dome.

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The main questions of the topic:

• Etiology and pathogenesis of GT.
• Classification.
• Clinic GT.
• Diagnostic methods.
• Emergency medical care, including during the evacuation stages.
• Correction of homeostasis disorders.
• Indications and principles of surgical treatment.

1. Hemothorax - accumulation of blood in the pleural cavity. Its cause is a closed or open chest injury of various etiology and volume with damage to the vessels of the chest wall (intercostal, internal thoracic artery), organs (lungs, heart, diaphragm), large vessels (aorta, vena cava and their intrathoracic branches), destructive inflammatory and oncological diseases, adhesions, surgical interventions.

2. Pathogenesis - internal bleeding, leading to accumulation of blood in the pleural cavity and compression of the lung on the side of the lesion, with possible displacement of the mediastinum, which leads to a clinic of acute respiratory and heart failure, anemia.

3. Classification:

1. by etiology: traumatic (including gunshot), pathological (a consequence of various diseases), postoperative;
2. in terms of blood loss: small (blood in the sinus, blood loss up to 500 ml); medium (up to the lower edge of the 4th rib, blood loss up to 1.5 l), large (up to the lower edge of the 2nd rib, blood loss up to 2 l), total (total darkening of the pleural cavity on the side of the lesion);
3. by dynamics: increasing GT; non-increasing;
4. according to the presence of complications: curtailed; infected.

4. Clinic - a picture of internal bleeding (weakness, pallor of the skin and mucous membranes, tachycardia, drop in blood pressure), difficulty breathing, dullness of percussion sound, weakening or absence of breathing on the side of the lesion.

5. Diagnosis - clinical data, plain chest radiography, pleural puncture with sampling:

• Ruvelua-Gregoire - if the blood in a test tube or tray coagulates, then this is a sign of ongoing bleeding, non-clotting - stopped;
• Effendiev - 5-10 ml of blood from the pleural cavity and an equal amount of distilled water are poured into a test tube. As a result, the blood was hemolyzed. If the hemolysate was evenly colored ("lacquer" blood) - the blood is not infected, if it contained a cloudy suspension, flakes - infected;

Thoracoscopy.

6. Treatment - general: hemostatic, antiplatelet, immunocorrective, symptomatic therapy, general and local antibiotic therapy for the prevention and treatment of HT infection, the introduction of fibrinolytic drugs for the prevention and treatment of clotted HT.

7. Indication for surgical treatment - ongoing bleeding; clotted large hemothorax, preventing the expansion of the lung; damage to vital organs.

It is preferable to start with video-assisted thoracoscopic interventions.

Recent publications testify to the increasing role of thoracoscopy in penetrating chest injury (PWG) [Getman VG, 1989; Bondarenko V.A., 1968]. CM. Kutepov (1977) identified the following indications for thoracoscopy in RG: lung injury complicated by hemo- and pneumothorax, suspicion of injury to the pericardium, heart, chest wall vessels, and thoracoabdominal injuries. V.M.Subbotin (1993) and R.S.Smith et al., (1993) propose to expand the indications for thoracoscopy as a safe method of diagnosis and treatment for chest trauma, but, unfortunately, they do not give the possible volumes of clotted hemothorax. With low localization of chest wounds on the left, in order to identify the condition of the diaphragm, the mandatory use of thoracoscopy is recommended. P.Thomas et al. (1995) consider this method as an aid to choosing the optimal thoracotomy incision, J.L. Sosa et al., (1994) - as a method for assessing damage and treatment by drainage, and A.V. Kasatov (1994) - as an alternative to thoracotomy.

Emergency thoracoscopy in PRG was performed in 23.3% of cases [Kutushev F.Kh. et al., 1989]. The fact that endoscopy significantly increases the possibilities of diagnosing and treating patients with traumatic pneumothorax is confirmed by the data of M.A. Patapenkova (1990). He believes that for thoracoscopy, the collapse of the lung should be more than 1/3, at the same time, he considers thoracoscopy indicated in all cases of PRG. The author also confirmed the data of A.N. Kabanova et al. (1988) that lung damage in PHR may be superficial when thoracotomy is not required.

One of the most common manifestations of WG is pneumothorax and hemothorax, and/or a combination of both. So, according to a number of authors, hemothorax was found in 50% [Shakhshaev M.R. et al., 1968], in 55.6% [Boitsov V.I., 1977], in 74.6% [Domedze G.P., 1969], in 64.9% [Demchenko P.S. et al., 1989] in patients with PRG, pneumothorax - in 42.7% [V.I. Boytsov, 1977], in 60% [Kosenok V.K., 1986], in 84% [Marchuk I.K., 1981] of those wounded in the chest.

According to our data, out of 606 wounded, hemothorax occurred in 220 (36.4%). In terms of volume, large hemothorax occurred in 25.5%, medium - in 39.3% and small hemothorax - in 35.0% of the observed. In 148 victims, the wounds were located on the left, in 62 - on the right, and in 10 - on both sides.

The formation of hemothorax was caused mainly by wounds located in the IV-VI intercostal space (56.2%). The sources of bleeding into the pleural cavity were: lungs - in 36%, intercostal arteries - in 33%, heart - in 19%, diaphragm - in 5%, pericardium - in 4% and internal thoracic artery - in 3% of cases.

In patients with hemothorax, upon admission to the hospital, the condition was assessed as satisfactory in 16%, moderate in 25%, severe in 45%, agonal in 10%, and clinical death in 4%. Upon admission to the hospital, 131 wounded (59.7%) underwent radiographic or fluoroscopic examination (31.3% were not examined due to the severity of the condition).

Of the 131 examined, the X-ray picture of hemothorax on the first day was detected in 68% of the victims, on the 2nd day in another 28%, on the 3rd day - in 3% and in 1% of the observed - only on the 4th day.

Thus, in 3-4% of the victims, radiological signs of hemothorax appear only on the 3-4th day. Therefore, it is necessary to conclude that victims with chest wounds, even without objective signs of a penetrating wound, should be hospitalized.

According to most authors, indications for thoracotomy are: heart injury, suspected injury to the heart or a large vessel, damage to the large bronchi or esophagus, ongoing intrapleural bleeding, tension pneumothorax that cannot be eliminated by punctures and drainage, injury to the thoracic lymphatic duct, foreign bodies in the pleural cavity [ Bekturov Kh.T., 1989; Lysenko B.F. et al., 1991; Gudimov B.S., Leskov V.N., 1968; Hirshberg A. et al., 1994; Coimbra R. et al., 1995].

Among the adherents of thoracotomy, there is no consensus about the moment of its implementation, when it will be most justified. The fact that there are no mandatory recommendations regarding the moment for the production of thoracotomy, as well as the need to determine it, is evidenced by the works of H. U. Zieren et al., (1992) and K.L. Mattox (1989).

The great possibilities of modern multidisciplinary medical institutions do not exclude, but on the contrary, predetermine the use of clear diagnostic and tactical programs. We cannot agree with the opinion of those surgeons who believe that "the approach to resolving the issue of determining surgical tactics for chest injuries should be individualized." The solution of tactical issues depends on the specific conditions of assistance.

Of the 220 people with hemothorax, 120 (63.6%) of the victims required thoracotomy, including 11.6% for resuscitation purposes.

With a large hemothorax, all patients were subjected to thoracotomy, with an average - 69.0%, and with a small one - 28%. Thoracotomies for medium and small hemothoraxes were performed on a delayed basis for clotted or infected hemothorax.

With clotted hemothorax, there is no complete clarity regarding the pathogenesis, the question of therapeutic tactics remains open. It is widely believed that the blood poured into the pleural cavity usually coagulates, then its fibrinolysis occurs, and after a few hours the blood becomes liquid again, although dense clots may also form [Vagner E.A., 1975].

To complete the judgment on the pathogenesis of post-traumatic clotted hemothorax, it seemed interesting to us to clarify the effect of mechanical hemolysis that occurs in hemothorax due to cardiorespiratory movements (“separator effect”) on the blood coagulation process. Mechanical hemolysis in in vitro experiments led to a fairly clear pattern in hemocoagulation. The study of hemocoagulation data in comparison with the severity of hemolysis made it possible to identify a pattern of changes in the blood coagulation system according to the type of DIC. It turned out that mechanical hemolysis, as a high-intensity external influence, leads to an acceleration of the continuous process of blood coagulation. Probably a similar situation occurs with hemorrhage into the pleural cavity in victims with chest trauma. The results of our studies suggest that in the pathogenesis of clotted hemothorax, an important link is the intensity of hemolysis in a certain volume per unit of time, due to cardiorespiratory movements. The less the severity of hemolysis (erythrocytolysis), the more likely the formation of clotted hemothorax. Thus, blood clots in the pleural cavity are formed immediately, or they do not happen in the next day. Another thing when it comes to fibrinothorax or fibrothorax.

The diagnosis of clotted hemothorax is established by the clinic (shortness of breath, pain, fever) and a typical x-ray picture (presence of homogeneous and intense blackout on the side of the lesion of the lower lung field or inhomogeneous blackout with fluid levels).

The study of the dynamics of morphostructural changes in the blood clot, pleura and lung confirmed us in the opinion that thoracotomy and removal of clotted hemothorax, performed in the first 5 days, prevent the development of pleural empyema, contribute to the most adequate restoration of the functional abilities of the lungs.

It should be noted that in the first period of the study, with continued bleeding, indications for thoracotomy were given without taking into account the volume of blood loss per unit of time. In a retrospective analysis of cases with thoracotomy, it can be assumed that it was justified only in 84.1% of cases.

In the second period of the study, with indications for emergency thoracotomy for hemothorax, the following principle was adhered to: simultaneous release of blood from the pleural cavity after its drainage with a volume of 1000 ml, with blood pressure not lower than 90 mm Hg. Art., fixed "as a starting point." If further blood loss within 1 hour was more than 250 ml, then a thoracotomy was performed. In the last three years, the percentage of thoracotomies does not exceed 11%.

Thoracic surgery is developing rapidly.