Traumatic hemothorax-frequent occurrence, especially in the center of Arts, where they treat patients with trauma. In the Houston hospital alone, 300 patients were registered during the year with hemothorax resulting from a penetrating injury . The incidence of hemothorax caused by penetrating or non-penetrative wound to the chest, depends on whether the act at the center of the victim’s car katastro Oscilloscopes, as well as persons with knife and gunshot wounds.
Diagnostics
The diagnosis of traumatic hemothorax should be kept in mind in any patient with a penetrating or non-penetrating chest injury. The diagnosis is usually set on the Ba Vania radiological detection of pleural effusion in patients with chest trauma. At the first radiologists Český examination hemothorax may remain nevyyavlen nym . Thus, out of 130 patients with hemothorax, emerged in the results –
When the review chest X-ray soon after the automobile injury found pleural you sweat and pneumothorax. The patient was made drainage of the pleural cavity by the method of thoracostomy . After 4 days, he was discharged from hospital without radiologically visible residual effects.
In 31 cases (24%) hemothorax was not detected on the primary radiograph . Authors schi melt that because in some cases, the X-ray in the supine position can not be identified hemothorax, whenever possible in patients with trauma is recommended ra- raphy of the chest in a standing position. However, some of these patients also showed no signs of hemothorax on a radiograph in a standing position. Consequently, patients with severe chest trauma need for vtornaya radiography through 24 hours after the accident. Regardless of the nature of the injury (penetrating or not Penitent) high incidence of pneumothorax odes but temporarily with hemothorax . Of the 114 patients with gemoto RARS arising out of the non-penetrating wounds, in 71 (62%) then simultaneously developed and pneumothorax [2], and from 373 patients with hemothorax caused penetrating wound Niemi, pneumothorax developed in 307 cases (83%) .
Treatment
Emergency drainage is recommended for patients with traumatic hemothorax [1-6]. In the past, some authors believed that drainage leads to a reduction in intrapleural pressure and, consequently, an increase in bleeding in the pleural cavity. However, if the bleeding is trace Corollary gap pleura, pleural the contact sheet Cove will contribute TAMP RUBAA and stop bleeding ‘ . If the source of bleeding is large suck rows, the slight decrease in pressure caused by the introduction of the core clicked will be insignificant compared with the intravascular pressure . The advantages of emergency administration of drainage by the method of thoracostomy are the following: 1) a more complete evacuation of blood from the pleural cavity; 2) complete cessation of bleeding, if it is a consequence of pleural rupture; 3) possibility NOSTA quantify blood loss; 4) decrease the probability Nosta subsequent development of pleural empyema, since blood is a good culture medium ; 5) blood from the pleural hydrochloric cavity outputted at drainage can be re-transfused to the patient; 6) rapid removal of blood from the pleural cavity reduces the likelihood of developing fibrotox .
Large-diameter drainage tubes should be used (36-40 Argyle), since blood clots are often observed. Beall et al . highly recommend administered drainage of fluids therein axillary line (fourth or fifth intercostal space ), as a result of trauma may experience high standing ku aperture floor . For suspected cardiac tamponade, vascular injury, infection pleura, optionally ud Lenia necrotic tissue in cases of penetrating injury of the chest wall with the suction air or extensive wounds bronchial air leakage is shown urgent thoracotomy . Another indication for emergency thoracotomy is ongoing intrapleural bleeding. The volume of bleeding, which would define the need torakoto mission, just not installed, as each case requires Xia individual approach . However, if the speed of the blood flow cheniya exceed 200 mL / h, and there are no signs of its termination, should seriously consider thoracotomy.
In the case of hemorrhage must ensure that it is not a consequence of incorrect placement of the catheter in cent tral vein . Mattox and Fisher reported 7 cases of traumatic hemothorax when continuing blood during resulted from incorrect installation or displacement of the catheter, introduced into a central vein. This diag ERA easily set by changing the form of the detachable plevu tral cavity during intravenous infusion of various liquid stey. Thoracotomy is required in approximately 20% of patients with hemothorax . Upon termination of operation of the core pushing it to be removed from the pleural cavity, as it may serve as a guide infection. If patients do not have other serious injuries, in most cases they can be discharged from the hospital 48 hours after the start of treatment .
Complications
In patients with traumatic hemothorax may have 4 types of pleural complications of blood clots delay in the pleural cavity, Intrapleural infection, pleural ny effusion and fibrothorax . Some authors to remove blood residues which can not be withdrawn through the core nazh recommend thoracotomy [1-3]; they believe that the absence in the pleural cavity of a large number of turning sheysya blood increases the likelihood of subsequent development of empyema and fibrothorax . However, a recent study This indicates that there is no need to remove blood clots . There were 118 patients with residual symptoms hemothorax and 290 patients in which they otsutst Vova after treatment by drainage. It was found that the incidence of empyema was comparable in both groups groin, and 84% of patients with residual symptoms in the late period of the pleura lesions were detected. This explores vanie indicates that not all patients with gemoto Rax, followed by residual effects, it is required that rakotomiya. Thoracotomy is indicated only in cases where blood clots take more than 30% hemithorax . For solution Niya blood clots, some authors recommend vnutriplev eral administration of streptokinase , but reports of cont liruemyh studies are not available.
Another complication is hemothorax empyema, koto paradise develops in 1-4% of cases . Patients post drank in a state of shock or a significant contamination of the pleura during trauma, the likelihood of developing empyema above. Empyema most commonly occurs in patients with concomitant abdominal trauma [4], and also in the continued Tel’nykh thoracostomy . Leche methods Nia patients with empyema are the same as in other cases bacta ble infection I pleural cavity . Since many patients with empyema complicating hemothorax are young healthy people, then, if the result of drainage and thoracotomy can not quickly eliminate the intrapleural infection, should we consider the retquestion of decortication.
The third type of complication, observed in patients with re motoraksom, is the formation of pleural effusion after removal of drainage. Wilson et al . It reported that 37 (13%) of 290 patients with hemothorax not accompanied by residual E phenomena appeared pleural effusion after removal of the drainage, and 40 (34%) of 118 patients with residual symptoms had pleural effusion to hospital discharge time . Of these 77 patients with pleural effusion in 20 developed village le of the drainage method torakostomii empyema, in other 57 patients the effusion resolved with minimal residual effects or without them . This observation shows that pleural effusion is a common type of complication of hemothorax after drainage by the method of thoracostomy . If there is a pleural effusion, it is necessary to make a diagnostic thoracocentesis to rule out intrapleural infection. In the absence of intrapleural infection pleural effusion usually spontaneously rassas INDICATES without any sequelae.
Fourth hemothorax complication is the development of Th cut a few weeks or months, diffuse pleural thickening, fibrothorax . This complication occurs in less than 1% of cases, even if blood clots are not removed during a trial thoracotomy . Fibrothorax more typical for patients with gemopnevmotoraksom , as well as in cases of hemothorax, oslozh nennogo infection of the pleural cavity. For the sake of Calne treatment fibrothorax a decortication of the lung . However, in most cases Dekort katsiyu should be done a few months after herbs we, because over time the degree of thickening of the pleura often decreases.
Iatrogenic pneumothorax
In identifying the patient hemothorax should consider’ve probability of its iatrogenic origin. The most frequent during cause of iatrogenic perforation is pneumothorax cent tral vein during percutaneous catheterization or the blood flow chenie from the aorta, resulting from translyumbalyyuy aortography Iatrogenic hemothorax may be due to thoracentesis or biopsy pleura. Patients with iatrogenic pneumothorax, as well as patients with traumatic pnevmotorak catfish, should be treated by drainage.