Coagulative hemothorax and pleurodesis

Hemothorax is one of the serious complications of chest trauma. In chest trauma, about 70% of the wounded have different degrees of hemothorax, and intrathoracic hemorrhage is also one of the important causes of early traumatic death. The sources of bleeding are: 1 heart or large blood vessel damage, including the aorta and its branches, the superior and inferior vena cava and the pulmonary artery. The amount of bleeding in this type of injury is numerous and fierce. Most of the wounded died on the scene, and only a few were sent back for treatment. 2 chest wall vascular injury, more common in the intercostal artery, vein and thoracic vessels, because it belongs to the systemic circulation, high pressure, mostly persistent bleeding, difficult to stop naturally, often need surgery to stop bleeding. 3 lung tissue injury bleeding. Because of the low pulmonary artery pressure, it only reaches 1/8 of the systemic pressure, and the circulating blood volume of the pulmonary vessels that are under pressure is significantly reduced compared with normal. Therefore, the hemorrhage of the lung parenchyma can be stopped naturally in a short time. There are not many people who have surgery to stop bleeding. The blood chest is divided into the amount of blood in the chest: 1 small amount of hemothorax: refers to the amount of blood in the pleural cavity below 500ml, X-ray chest radiograph sees the rib angle becomes dull, the liquid surface does not exceed the dome plane. 2 medium amount of blood chest: pleural volume of blood in the 500 ~ 1500ml, X-ray chest radiograph see the effusion up to the hilar plane. 3 a large number of hemothorax: the amount of blood is above 1500ml, X-ray chest radiograph sees the effusion over the hilar plane (Figure 5.9.6.2-1-). A small amount of hemothorax has no bleeding symptoms and signs, most of which were found during X-ray examination. More than a medium amount of blood and chest, due to acute massive blood loss caused by rapid reduction of blood volume, decreased cardiac output, resulting in hemorrhagic shock, while a large amount of blood in the chest can compress the lungs, lung collapse, mediastinal shift, resulting in similar pneumothorax Respiratory and circulatory dysfunction. The wounded were restless, pale, cold, weak pulse, blood pressure and difficulty breathing. During the physical examination, it can be seen that the respiratory movement of the injured side is weakened, the intercostal space is flattened, the trachea is moved to the healthy side, the percussion is a real sound, and the breath sound is weakened or disappeared. Under normal circumstances, blood flows into the pleural cavity, and the fibrin is accumulated due to the movement of the diaphragm, heart, and lung, and the fibrin is precipitated and loses coagulation. However, if the amount of bleeding is high and the bleeding rate is fast, the defibrination effect is incomplete, and the blood can still coagulate to form a coagulative hemothorax. For open or closed chest trauma patients, if there is respiratory, circulatory dysfunction and internal bleeding, the possibility of hemothorax should be considered. X-ray chest examination showed that there was a shadow of pleural effusion on the injured side, and the mediastinum moved to the healthy side. When the pneumothorax was combined, the fluid level and lung collapse were more clear. In addition to the liquid level, the ultrasound examination also helps to estimate the amount of blood and the choice of the puncture site. Thoracic puncture can be diagnosed by withdrawing blood without coagulation. If it is a coagulative hemothorax, it is not easy to withdraw blood or the amount of bleeding is small. It should be combined with clinical manifestations, X-ray examination and ultrasound examination. In addition to the diagnosis of hemothorax in the early stage, it is necessary to determine whether the intrathoracic hemorrhage is stopped or continues. In the following cases, chest bleeding should be considered. 1 The pulse is weak and fast, and the blood pressure is not easy to maintain. Anti-shock measures such as blood transfusion and fluid replacement are not improved, or deteriorate soon after the temporary improvement. 2 Thoracic puncture and blood is quickly solidified, indicating that there is still active bleeding. 3 chest puncture blood, and soon see the increase in blood. 4 hemoglobin and red blood cells progressive decline. 5 Place the closed thoracic drainage, and drain more than 200ml per hour for more than 3h. The blood drawn out is bright red, and its hemoglobin measurement and red blood cell count are close to the surrounding blood. Or 24h drainage rate exceeds 1000ml. The blood in the thoracic cavity is prone to infection, especially in the chest during the war. There are often foreign bodies or shrapnel. If not removed in time, the infection rate of suppuration is higher. However, in the early stage of infection, it should be differentiated from the increase in moderate temperature and leukocytosis caused by pleural hemorrhage itself. If the blood chest occurs, the main manifestations are as follows: 1 body temperature and white blood cells are significantly increased, accompanied by other symptoms of systemic poisoning. 2 distilled water test: 1 ml of pleural effusion was taken out, placed in a glass test tube, 5 ml of distilled water was added, mixed and left for 3 min. If the solution was light red and transparent, it means no infection. If there is turbidity or flocculation, it is already infected. 3 The blood drawn out was checked for red and white blood cell ratio, and the normal red and white blood cell ratio was 500:1. When there is an infection, the white blood cell count increases, and the ratio of red and white blood cells becomes 100:1, which can be determined as an existing infection. 4 The blood was taken out for smear and bacterial culture, and the positive ones proved that they were infected. Antibiotic susceptibility test should be used to provide reference for the selection of antibiotics. Those who have not found hemothorax in the early stage of chest trauma should be alert to the occurrence of delayed hemothorax. There is no clinical and X-ray findings of hemothorax after this type of injury, but a few days later it was confirmed that there was a hemothorax, even a large amount of hemothorax. The reason may be that the rib fracture was broken when the rib fracture was active or closed. The blood clot clots fall off. It may also be related to factors such as lung contusion and laceration, chest wall small vessel injury and other factors. Therefore, chest X-ray examination should be performed several times within 3 weeks after chest trauma to avoid missed diagnosis and misdiagnosis of delayed hemothorax. The principle of treatment of hemothorax is mainly to prevent and treat shock, to stop bleeding in active bleeding, to clear the blood in the chest, to prevent infection, and to deal with complications and complications caused by hemothorax in time. Treatment of diseases: traumatic hemothorax Indication Small coagulative hemothorax, streptokinase can be injected into the chest in the early stage, and the dissolved hemorrhage can be withdrawn 24 hours later, and can be repeated many times. Physiotherapy is still available, and most can be absorbed without surgery. Moderate or higher coagulative hemothorax, in addition to possible secondary infections, also affects lung function due to the mechanism of blood chest, so after the situation of the wounded is stable, early surgery should be sought. Generally, the operation is relatively simple in about 2 weeks. If the time is long, the hematoma becomes mechanized and becomes a fiber chest. It is difficult to perform surgery and requires pulmonary fiber stripping. Surgical procedure 1. After entering the chest cavity, remove blood, remove clots and fibrin film attached to the surface of the lungs. 2. If it is a fiber chest, fiberboard stripping should be performed. Cut a small opening in the fiberboard surface of the lung surface, find the gap between the fiberboard and the lung surface, and separate the fiberboard from the lung surface with a small gauze mass. For loose parts, the finger can be used for blunt separation. When the adhesion is tight, use a sharp device to separate. If the small piece is too tightly adhered, it can be peeled off around it and the small fiber board remains in place. Fibrous plates located in the paravertebral sulcus and the front chest wall must be stripped to facilitate postoperative lung expansion. If the fiberboard on the diaphragm is difficult to peel off, it may not be peeled off, but the fiberboard covering the lower lobe of the lung should be peeled off. 3. Check the expansion of the lungs and whether there is any air leakage. The small lung surface is not sutured, and the larger air leakage is applied to the suture. 4. After completely stopping bleeding, flush the chest cavity and place a thick chest drainage tube.