Chapter 408 Hemothorax
Hemothorax is an accumulation of blood in the pleural cavity. It is rare in children.
Etiology
Bleeding into the chest cavity most commonly occurs after chest trauma, either blunt or penetrating. It can be the result of iatrogenic trauma, including surgical procedures and venous line insertion. Hemothorax can also result from erosion of a blood vessel in association with inflammatory processes such as tuberculosis and empyema. It may complicate a variety of congenital anomalies, including sequestration, patent ductus arteriosus, and pulmonary arteriovenous malformation. It is also an occasional manifestation of intrathoracic neoplasms, costal exostoses, blood dyscrasias, bleeding diatheses, or thrombolytic therapy. Rupture of an aneurysm is unlikely during childhood. Hemothorax may occur spontaneously in neonates and older children. A pleural hemorrhage associated with a pneumothorax is a hemopneumothorax; it is usually due to a ruptured bulla with lung volume loss causing a torn pleural adhesion.
Clinical Manifestations
In addition to the symptoms and signs of pleural effusion (Chapter 404.2), hemothorax is associated with hemodynamic compromise related to the amount and rapidity of bleeding.
Diagnosis
The diagnosis of a hemothorax is initially suspected from radiographs or CT scans but can be made only with thoracentesis (Fig. 408-1). In every case, an effort must be made to determine and treat the cause.
Treatment
Initial therapy is tube thoracostomy. Surgical intervention may be required to control active bleeding, and transfusion may be indicated. Inadequate removal of blood in extensive hemothorax may lead to substantial restrictive disease secondary to organization of fibrin; fibrinolytic therapy or a decortication procedure may then be necessary.
Hunt I, Thakar C, Southon R, et al. Establishing a role for intra-pleural fibrinolysis in managing traumatic haemothoraces. Interact Cardiovasc Thorac Surg. 2009;8:129-133.
Kim ES, Kang JY, Pyo CH, et al. 12-year experience of spontaneous hemopneumothorax. Ann Thorac Cardiovasc Surg. 2008;14:149-153.
Shehata SM, Shabaan BS. Diaphragmatic injuries in children after blunt abdominal trauma. J Pediatr Surg. 2006;41:1727-1731.