Hemothorax | Medical Science Optional Notes for UPSC PDF Download

Thoracic Injuries Management Overview

Non-Operative Management

• Roughly 80% of chest injuries can be managed without surgery.
• A successful outcome relies on prompt physiological resuscitation followed by an accurate diagnosis.

'Deadly Dozen' Life-Threatening Chest Injuries:

Immediately Life-Threatening (Addressed in Primary Survey):

• Airway Obstruction: Addressed through early intubation.
• Tension Pneumothorax: Requires immediate decompression, typically through cannula insertion and subsequent chest tube placement.
• Pericardial Tamponade: Urgent treatment involves operative measures like subxiphoid window or open surgery.

Potentially Life-Threatening (Identified in Secondary Survey):

• Open Pneumothorax (Sucking Chest Wound): Urgent closure using sterile occlusive dressing and subsequent chest tube insertion.
• Massive Hemothorax: Correcting hypovolemic shock, intercostal drain insertion, and potential thoracotomy for excessive bleeding.
• Flail Chest: Management involves oxygen administration, pain relief, physiotherapy, and in severe cases, mechanical ventilation or surgical fixation of ribs.

Important Considerations in Open Pneumothorax/Hemothorax Management

• Use a sufficiently large tube for drainage in adults (28FG or larger).
• Consider low-pressure suction if lung reinflation doesn't occur.
• Chest X-rays aid in identifying blood presence.
• Physiotherapy and mobilization initiation should be prompt.

Specific Details for Immediate and Secondary Life-Threatening Chest Injuries

• Airway Obstruction: Intubation is key.
• Tension Pneumothorax: Quick decompression via cannula insertion and subsequent chest tube placement.
• Pericardial Tamponade: Immediate operative measures.
• Open Pneumothorax: Swift closure with occlusive dressing, followed by chest tube insertion.
• Massive Hemothorax: Address hypovolemic shock, consider thoracotomy for excessive bleeding.
• Flail Chest: Manage with oxygen, pain relief, physiotherapy, and in severe cases, mechanical ventilation or rib fixation surgically.

Key Points in Management

• Size matters for drainage tubes (adults: 28FG or larger).
• Monitor and adjust drainage suction.
• Chest X-rays aid in diagnosis.
• Early initiation of physiotherapy and mobilization is crucial.

Thoracic injuries

• Aortic Injuries:
  • Often a leading cause of sudden death following road traffic accidents (RTA).
  • Manifestations include significant systolic blood pressure asymmetry (between upper limbs or between upper and lower limbs), widened pulse pressure, and chest wall contusion.
  • Diagnosis through methods such as Chest X-ray (indicating a widened mediastinum), Chest CT, and transesophageal 2D Echo.
  • Management involves controlling systolic blood pressure, utilizing endovascular intra-aortic stents or grafts (dacron graft), or direct surgical repair of the tear.
• Tracheobronchial Injuries:
  • Marked by subcutaneous emphysema leading to respiratory compromise.
  • Notable air leakage from the chest drain.
  • Diagnostic bronchoscopy.
  • Treatment includes intubation of the unaffected bronchus followed by surgical repair.
• Myocardial Contusion (Blunt Myocardial Injury):
  • Identification through ECG abnormalities and 2D echo (detecting wall motion abnormalities).
  • Management involves close monitoring, detecting arrhythmias, and providing prompt treatment.
• Rupture of Diaphragm:
  • Consider diaphragmatic injury in cases of penetrating trauma below the fifth intercostal space.
  • Often asymptomatic; abdominal contents herniate into the chest, risking strangulation with a high mortality rate.
  • Diagnosis via chest radiography (after nasogastric tube placement), with video-assisted thoracoscopy (VATS) or laparoscopy offering the most accurate evaluation.
  • Operative repair is recommended in all cases, conducted from the abdominal side to rule out hollow viscus injury.
• Esophageal Injuries:
  • Presentation includes odynophagia, subcutaneous or mediastinal emphysema, pleural effusion, air in the perioesophageal space, and unexplained fever.
  • Primarily caused by penetrating injuries.
  • Diagnosis involves a combination of oesophagogram in the decubitus position and oesophagoscopy.
  • Operative repair is the standard approach for any identified defect, accompanied by drainage.
• Pulmonary Contusion:
  • A significant contributor to worsening hypoxemia post-blunt trauma.
  • Signs may include hemoptysis or blood in the endotracheal tube.
  • Confirmation through contrast CT.
  • Treatment strategies encompass oxygen administration, adequate analgesia, and pulmonary toilet, with mechanical ventilation reserved for severe cases.

Thoracic injuries-lnvestigations

• Extended Focused Assessment with Sonar for Trauma (eFAST):
  • Examines the pericardial sac, pleural sacs, peritoneal sacs (including pericolic gutters and subdiaphragmatic spaces), and the pelvis.
• Underwater Chest Drain:
  • When time is critical and radiological investigations are not feasible, inserting an underwater chest drainage tube serves both diagnostic and therapeutic purposes.
• Chest Radiograph:
  • For hemodynamically unstable patients, an AP view is essential.
  • An erect PA view is more effective in detecting small pneumothoraces.
• Computed Tomography (CT):
  • Contrast-enhanced CT aids in 3D reconstruction.
  • However, it's crucial not to prioritize radiological investigations over resuscitation for unstable patients. Resuscitation for all chest injuries should adhere to traditional ATLS principles: A (Airway), B (Breathing), C (Circulation), D (Disability - neurology), E (Environment and Exposure).
• Indications for Emergency Room Thoracotomy:
  • Include massive hemothorax, suspected cardiac tamponade, and witnessed cardiac arrest in the resuscitation area.
  • The standard approach is a left anterior thoracotomy.

Hemothorax-Repeats

Q1: How would you manage a 50-year old man admitted with dyspnea following blunt trauma to the chest? (2011)

Q2: A 35-year-old male sustains road traffic accident. On general examination, he is oriented and pale, pulse rate 120/minute, BP 90/60 mm of Hg, respiratory rate 32/minute. Chest contusion is present and right chest wall with decreased movement. On auscultation decreased breathing sound (Right) with stony dullness (Right) on percussion. (2017)
(i) Discuss the differential diagnosis.
(ii) How would you investigate?
(iii) Give the treatment of the above-mentioned clinical scenario.