hemothorax
Introduction
Blood chest introduction The pleural cavity accumulates blood called the blood chest, while the blood and air accumulate is called the blood pneumothorax. In the chest wound patient, the blood chest is very common. Bleeding can occur from intercostal vessels, intrathoracic vessels, pulmonary lacerations, or major and intravascular chest trauma. The number of hemothorax depends on the size of the blood vessel rupture, the blood pressure level and the duration of the bleeding. Most of the lung tissue hemorrhage is caused by the rupture of the rib fracture and the pleura and the lung. Because of the small ruptured blood vessels, the pulmonary blood circulation is low, and the bleeding is Often can be closed by the blood clot and stop by itself, the general amount of bleeding is not much. Intercostal artery or internal thoracic artery rupture, due to high blood pressure in the systemic circulation, bleeding is not easy to stop by itself, and the amount of bleeding is more. Large blood vessels in the heart or chest, such as the aorta and its branches, the superior and inferior vena cava and pulmonary arteriovenous rupture, the amount of bleeding is large, the injury is heavy, the patient often died of shock in a short period of time due to a large number of blood loss. basic knowledge The proportion of illness: 0.0025%, more common in car accidents Susceptible people: no specific population Mode of infection: non-infectious Complications: pneumothorax, blood pneumothorax, shock
Cause
Hematopoietic cause
(1) Causes of the disease
According to the causes and mechanisms of hemothorax, hemothorax can be divided into traumatic hemothorax (traumatic haemothorax) and nontraumatic hemothorax (nontraumatic haemothorax). Most hemothorax is caused by penetrating or blunt chest trauma. Caused by non-traumatic hemothorax is rare, can be secondary to some chest or systemic diseases, very few patients can not find a clear cause of bleeding, non-traumatic hemothorax, also known as spontaneous hemothorax ( Spontaneous haemothorax), these patients have no history of trauma, but sometimes there may be cough, increased abdominal pressure, weight, fatigue, exercise, sudden change of body position and other incentives, although spontaneous hemothorax is rare, but the causes are diverse, if Its lack of understanding and understanding often leads to clinical missed diagnosis and misdiagnosis, resulting in incorrect treatment and serious consequences. Non-traumatic blood chest has no history of trauma, and its clinical manifestations are similar to traumatic hemothorax, mainly manifested as internal bleeding and intrathoracic The signs of organ compression, so it is divided into idiopathic spontaneous haemothorax, infectious haemothorax, endometriosis according to its etiology. Can cause hemothorax hemothorax other causes.
A penetrating wall or a lung, a large blood vessel in the chest, or a penetrating injury or a blunt injury can cause a blood in the pleural cavity called a traumatic hemothorax, and a pneumothorax is called a traumatic blood pneumothorax.
According to the clinical data of 47 patients with spontaneous hemothorax in a hospital, spontaneous hemothorax is not uncommon in clinical practice, accounting for 5.8% of spontaneous pneumothorax in hospital during the same period. It generally has obvious incentives and typical clinical manifestations such as chest pain and dyspnea. Loss of blood and so on.
(two) pathogenesis
The blood chest can have the following sources: 1 lung tissue laceration hemorrhage, due to lower pulmonary artery pressure (1/6 to 1/4 of the aorta), small amount of bleeding, more can stop by itself; 2 chest wall vascular rupture (intercostal space Blood vessels or blood vessels in the thoracic cavity), bleeding from the systemic circulation, higher pressure, more bleeding, and not easy to stop, often need surgery to stop bleeding; 3 heart or large blood vessel bleeding (aorta, pulmonary, vein, vena cava, etc.), more For acute hemorrhage, hemorrhagic shock occurs, and if it cannot be rescued in time, it can often be fatal.
Intrathoracic hemorrhage has two characteristics. On the one hand, the pressure in the thoracic cavity is low, the inhalation is negative pressure, the chest wall and the lungs continue to move with the breathing, causing the thoracic hemorrhage to be difficult to stop and coagulate, especially when the larger blood vessels are damaged. Often manifested as persistent, progressive bleeding, on the other hand, the pressure of the pulmonary circulation is low, the average pulmonary artery pressure is about 2.0kPa (15mmHg), the chest cavity is a fixed closed body cavity, when the intrathoracic pressure is due to various reasons, such as pneumothorax or chest cavity When the internal blood rises, the non-severe bleeding can often stop by itself, and one side of the chest can accumulate 40% of the circulating blood volume.
Prevention
Blood chest prevention
1. Prevention and treatment of chest trauma, timely and correct treatment of rib fractures.
2. Active treatment for the cause.
3. At the time of treatment, the pleural cavity should be estimated. When it is estimated that the blood in the thoracic cavity is less than 200ml, the chest should be performed early, puncture should be used to purify the blood, promote lung expansion, improve respiratory function, for 500ml hemothorax, Early placement of closed thoracic drainage can discharge blood and gas as soon as possible, so that the lungs can be re-expanded in time. It is also a powerful measure to prevent intrathoracic infection. At the same time, it can monitor the leakage and active bleeding, so that the patient is in a safe position. Autologous blood reinfusion can still be considered.
4. Antibiotic treatment to prevent infection.
Complication
Hemorrhage complications Complications, pneumothorax, blood, chest shock
Concurrent pneumothorax and blood pneumothorax, if the blood chest is not treated in time, as it develops, it will lead to dyspnea, shock, chest infection, coagulative hemothorax and other complications. Shock often shows rapid pulse, blood pressure, and breathing. Short-term, etc., when concurrent infections, there are symptoms of high fever, chills, fatigue, sweating and so on.
Symptom
Hematosema Symptoms Common Symptoms Cold sweats Difficulty, pale, traumatic, breathless sounds, chills, shortness of breath, shortness of breath, blood pressure, internal bleeding, low fever
A small amount of blood chest (500ml or less), if the patient's physical condition is better, the bleeding speed is not fast, there is no obvious symptoms, a large number of blood chest (1000ml or more), and the bleeding speed is faster, can appear pale, cold sweat, pulse speed And weak, shortness of breath, blood pressure drop and other signs of internal bleeding and signs of cardiopulmonary compression, physical examination can find that the intercostal space is full, the trachea shifts to the healthy side, the percussion is voiced, the heart shifts to the healthy side, and the auscultation breath sounds weaken or disappear. Patients with blood-thoraxic chest have a drum sound in the upper chest, and the lower chest is diagnosed with dullness. The patients with hemothorax caused by pulmonary laceration are often accompanied by hemoptysis. Patients with open blood-thoracic chest can directly observe the blood rushing from the mouth. According to this, the severity of intrathoracic hemorrhage can be estimated.
Examine
Blood chest examination
1. The peripheral blood red blood cells of patients with massive bleeding decreased significantly, and hemoglobin also decreased significantly.
2. X-ray chest
When the blood volume is less than 200ml, X-ray chest X-ray is difficult to make a diagnosis. When the blood volume is less than 500ml, the rib angle becomes dull. When the pneumothorax is combined, there is a liquid level in the rib angle area. The lying position is often missed. Take an upright position, and follow the time (6h, 24h after injury) for X-ray chest radiography. When the blood volume is about 1000ml, the effusion shadow reaches the lower scapular plane. When the blood volume exceeds 1500ml, the effusion shadow exceeds the hilum. Horizontal, even showing a dense chest shadow and mediastinal shift.
3. Ultrasound examination
The liquid level can be seen. When the thoracic puncture is not coagulated, the diagnosis can be confirmed. In the coagulative hemothorax, it is not easy to draw blood or the amount of extraction is small, but the internal bleeding symptoms are aggravated, and the chest X-ray shows the amount of effusion. Increased, in addition, in the case of severe clinical symptoms, according to physical diagnosis and examination, the first to do a chest puncture to establish a diagnosis, without waiting or at all can not first X-ray examination.
Diagnosis
Hematodialysis diagnosis
diagnosis
History of chest trauma (including iatrogenic) Spontaneous hemothorax has cough, increased abdominal pressure, weight, fatigue, exercise, sudden change of body position and other incentives, with corresponding clinical manifestations and chest X-ray results can generally make a diagnosis, chest Puncture to establish a diagnosis.
Pleural effusion can cause hypothermia, but if there is a sign of purulent infection such as chills and high fever, increased white blood cell count, the puncture should be sent for bacterial smear and culture examination.
The blood chest develops to form a fiber chest. If the range is larger, the thoracic collapse of the disease side may occur, the respiratory movement is weakened, the trachea and mediastinum are displaced to the disease side, and the lung ventilation is reduced. X-ray examination shows the dense shadow caused by the fiber plate.
The following conditions indicate that bleeding is still continuing to be highly vigilant:
1 The patient is in severe shock with obvious dyspnea, the affected intercostal space is widened, the sputum is turbid, the trachea and mediastinum are displaced to the healthy side, and the peripheral hemoglobin is often lower than 90-100g/L.
2 open chest trauma with shock state, a large amount of blood with the breath from the wound;
3 The blood drawn by the thoracic puncture is quickly coagulated (it is definitely not mistakenly inserted into the blood vessel), indicating that there is active bleeding in the chest;
4 After transfusion and blood rehydration, blood pressure does not rise or rise and then declines rapidly;
5 Repeated measurement of hemoglobin around the human body, red blood cell count, hematocrit, continuous progressive decline;
6 pleural effusion without bleeding, but internal bleeding symptoms worsened, X-ray chest showed pleural cavity shadow continues to increase; 7 placed thoracic closed drainage, drainage per hour more than 200ml and lasted more than 2h, or 24h drainage more than 1000ml ; 8 chest drainage blood red, high temperature, its hemoglobin determination and red blood cell count is similar to the surrounding blood.
Differential diagnosis
1, pneumothorax
(1) closed (simple) pneumothorax
In the case of expiratory lung retraction, or due to the oozing exudate, the visceral pleural rupture is closed by itself, no air leaks into the pleural cavity, and the pressure in the pleural cavity shows an increase in pressure. After pumping, the pressure drops. Without re-up, it means that the mouth is no longer leaking, the residual gas in the pleural cavity will be absorbed by itself, the pressure in the pleural cavity can maintain the negative pressure, and the lungs will gradually re-expand.
(2) Tension (high pressure) pneumothorax
The pleural rupture forms a flap, which opens when inhaling, and the air leaks into the pleural cavity. When the breath is closed, the gas in the pleural cavity can no longer be returned to the respiratory tract through the breach, and the result is that the gas in the pleural cavity is more and more accumulated. More, the formation of high pressure, the lungs are under pressure, breathing difficulties, the mediastinum pushes to the healthy side, the circulation is also impeded, urgent venting is needed to relieve the symptoms, if the pressure in the affected pleural cavity rises, after pumping to negative pressure, soon The positive pressure should be restored, and the continuous pleural ventilator should be installed. The tension pneumothorax is suddenly increased in the thoracic cavity, the lung is compressed, the mediastinum is displaced, and severe respiratory circulatory disorder occurs. The patient has nervous expression, chest tightness, and even arrhythmia. Struggling to sit up, irritability, sputum, cold sweat, fast pulse, collapse, and even respiratory failure, unconscious.
(3) Traffic (open) pneumothorax
Because there are adhesions and traction between the two layers of pleura, the break is continuously opened. When inhaling and exhaling, the air is free to enter and exit the pleural cavity. The pressure in the affected side of the pleural cavity is 0 or so. After pumping for several minutes, the pressure is not Reduced, patients often have heavy factors, holding breath, strenuous exercise and other predisposing factors, but there are also pneumothorax in sleep, the patient suddenly feels a side of chest pain, shortness of breath, suffocation, may have cough, but less, a small amount of closed pneumothorax There is anxious, but gradually stabilizes after a few hours, X-rays may not be able to show lung compression. If the amount of gas is large or there is extensive lung disease, the patient often cannot be supine. If lying on the side, it is forced to suffer from pneumothorax. Side to the upper, in order to reduce shortness of breath, the patient's difficulty in breathing and the amount of gas accumulation and the extent of the original intralesional lesions, when there is pleural adhesions and pulmonary dysfunction, even a small amount of localized pneumothorax may be obvious chest pain and shortness of breath.
2, blood gas chest :
Blood pneumothorax is a serious disease in spontaneous pneumothorax. The disease is more dangerous. Most patients have obvious causes of onset, such as strenuous activity, excessive weight bearing, etc. Most of the causes of hemothorax are suddenly torn by two layers of interthoracic adhesions between the chest wall. Cracked, a small number of tumor invasion and giant lung rupture caused by the disease, because the disease has both lung compression and bleeding, so the symptoms are heavier, the patient has both air urgency, chest tightness and other respiratory symptoms, but also palpitations, shock and other circulatory symptoms The severity of the patient's symptoms is related to lung compression and bleeding.
The disease has always advocated surgery after diagnosis. It is believed that delaying surgery may endanger the life of the patient, and the chest cavity may be caused by chest congestion, which may cause lung function damage. However, the author believes that as long as the observation is close and the treatment is proper, most blood-thoracic patients can Avoid surgical trauma, because the tear of the adhesive tape is mostly small blood vessel damage or capillary oozing, not a major vascular trauma caused by direct violence, so it is appropriate to give sufficient observation and conservative treatment time, specifically under closed drainage Observing the amount of bleeding, as long as there is no obvious blood pressure drop and heart rate gradually increase, the majority of patients with hemothorax can be cured by conservative treatment, especially in the early stage of closed drainage, due to partial re-expansion of the lungs and chest The blood coagulation can lead to a decrease in blood pressure due to the relative lack of circulating blood volume, and the heart rate is accelerated. This is a transient shock. Do not think that bleeding is caused by it. The author found in practice that in the early stage of closed drainage The use of intermittent tube can avoid the occurrence of shock.
3, the transverse rupture
After chest trauma, the diaphragm ruptures, the stomach into the chest cavity, the patient may have difficulty breathing, shock and other symptoms. X-ray chest radiograph shows the lower air level of the chest cavity, which can be misdiagnosed as a traumatic blood pneumothorax. Gastrointestinal peristalsis can sometimes be heard on the lower chest, and the placement of a contrast agent in the stomach tube can assist in the identification.
4, old pleural effusion
In patients with old pleural effusions with unknown medical history, the chest radiograph after chest trauma shows the shadow of chest fluid, which can be misdiagnosed as traumatic hemothorax. The chest fluid can be distinguished by yellow liquid or old blood liquid.
5, traumatic chylothorax
Traumatic hemothorax occurs mostly in the early post-traumatic period. A few delayed traumatic hemothorax can occur 5 to 18 days after injury. Traumatic chylothorax often occurs about 2 weeks after trauma, and can be associated with delayed hemothorax. Confusion, but the former is closely related to the diet, and the chyle challenge test can help identify the nature of the specimen collected by thoracentesis and the chyle test can be identified.
6, empyema
The accumulation of blood in the thoracic cavity can cause moderate body temperature increase and leukocytosis, which must be differentiated from empyema formed by secondary infection of hemothorax. The manifestations of secondary hemorrhage after infection are:
1 high fever, chills, fatigue, sweating, white blood cell count is significantly increased and poisoning particles can appear;
2 chest blood pumping blood smear red white blood cell normal ratio of 500:1, such as leukocytosis, red white blood cell ratio of 100:1, can be identified as existing infection;
3 Put 1ml of chest fluid in a test tube, add 5ml of distilled water, mix and leave for 3min, the above solution is light red and transparent, indicating no infection, if the solution is turbid or flocculation, it has been secondary infection;
4 The pleural fluid is used for smear examination and bacterial culture, and as an antibacterial drug sensitive test, it can assist in identifying and guiding the treatment.
