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AIP: Trauma > Massive haemothorax > Flashcards

Massive haemothorax Flashcards

1
Q

What is a haemothorax?

A

pleural effusion with a haematocrit >50% of peripheral blood haematocrit

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2
Q

What are 7 causes of haemothorax?

A
  1. Trauma
  2. Iatrogenic
  3. Malignancy
  4. Pulmonary infarction
  5. Pneumothorax
  6. Thoracic endometriosis
  7. Aortic rupture
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3
Q

What is the definition of massive haemothorax?

A

>1500 cm3 (1.5L) of blood in the hemithorax OR one third of the patient’s blood volume in the pleural cavity

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4
Q

What is the commonest cause of massive haemothorax?

A

trauma

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5
Q

What are 3 possible outcomes of large volumes of residual blood in the pleural space?

A

it will clot and:

  1. may lead to pleural thickening
  2. empyema
  3. trapped lung
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6
Q

What is haemothorax an example of?

A

pleural effusion - accumulation of abnormal volumes (>10-20ml) of fluid in the pleural space

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7
Q

For pleural effusions in general, what are 2 classes of pleural effusion?

A

transudate and exudate

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8
Q

What is the definition of a transudate pleural effusion?

A

<30g/L protein

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9
Q

What is the definition of an exudate pleural effusion?

A

>30g/L protein

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10
Q

What are 4 causes of a transudate pleural effusion?

A
  1. Heart failure (most common transudate cause)
  2. Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
  3. Hypothyroidism
  4. Meigs’ syndrome
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11
Q

What are 7 causes of an exudate pleural effusion?

A
  1. Infection: pneumonia (most common exudate cause), TB, subphrenic abscess
  2. Connective tissue disease: RA, SLE
  3. Neoplasia: lung cancer, mesothelioma, metastases
  4. Pancreatitis
  5. Pulmonary embolism
  6. Dressler’s syndrome
  7. Yellow nail syndrome
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12
Q

What are 3 possible symptoms of pleural effusion?

A
  1. Dypsnoea
  2. Non-productive cough
  3. Chest pain
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13
Q

What are 3 classic examination findings with pleural effusion?

A
  1. Dullness to percussion
  2. Reduced breath sounds
  3. Reduced chest expansion
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14
Q

What are the 2 key aspects of investigatino of pleural effusions?

A
  1. Imaging
  2. Pleural aspiration
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15
Q

What are 3 types of imaging to perform in pleural effusion?

A
  1. Posterior-anterior (PA) chest x-rays in all patients
  2. Ultrasound
  3. Contrast CT
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16
Q

What is the benefit of performing an ultrasound in pleural effusion? 2 things

A
  • increases likelihood of successful pleural aspiraton
  • sensitive for detecting pleural fluid septations
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17
Q

What is the benefit of performing a contrast CT in pleural effusin?

A

investigate underlying cause, particularly for exudative effusions

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18
Q

How should pleural aspiration be performed in pleural effusion?

A
  • use ultrasound guidance to reduce complication rate
  • use a 21G needle and 50ml syringe
  • send fluid for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
19
Q

What are the 5 things that fluid from an aspiration from pleural effusino should be sent for?

A
  1. pH
  2. protein
  3. lactate dehydrogenase (LDH)
  4. cytology
  5. microbiology
20
Q

What is the name of the criteria that can be applied to distinguish between a transudate and exudate pleural effusion?

A

Light’s criteria

21
Q

When do the British Thoracic Society recommend using Light’s criteria?

A

borderline cases: if protein level is between 25-25 g/L

22
Q

What do Light’s criteria state for differentiating borderline cases?

A

exudate is likely if at least 1 of the following met:

  • pleural fluid protein divided by serum protein >0.5
  • pleural fluid LDH divided by serum LDH >0.6
  • pleural fluid LDH >2/3x the upper limit of normal serum LDH
23
Q

What 2 conditions could low glucose in pleural fluid point towards?

A
  1. Rheumatoid arthritis
  2. Tuberculosis
24
Q

What 2 things could raised amylase in pleural fluid indicate?

A
  1. Pancreatitis
  2. Oesophageal perforation
25
Q

What 3 conditions could heavy blood staining of pleural fluid indicate?

A
  1. Mesothelioma
  2. Pulmonary embolism
  3. Tuberculosis
26
Q

What investigation should be performed in all patients with a pleural effusion in association with sepsis/pneumonic illness?

A

diagnostic pleural fluid sampling

27
Q

When sampling fluid from a pleural effusion in association with sepsis/pneumonic illness, what are 2 indications to insert a chest drain?

A
  1. If fluid is purulent or turbid/cloudy
  2. If clear but pH <7.2 in patients with suspected pleural infection
28
Q

What are 4 options for management of recurrent pleural effusion?

A
  1. Recurrent aspiration
  2. Pleurodesis
  3. Indwelling pleural catheter
  4. Drug management to alleviate symptoms e.g. opioids to relieve dyspnoea
29
Q

What type of mechanism of injury tends to cause haemothorax?

A

penetrating; blunt; or blast

30
Q

What are 4 possible clinical features of haemothorax?

A
  1. non-specific signs of penetrating chest injury, external bruising or swelling, or fractured ribs with crepitus
  2. tachypnoea and hypoxia
  3. localising signs of hypomobility of chest wall, dull to percussion, reduced breath sounds on affected side
  4. tachycardia and hypotension from internal haemorrhage
31
Q

What are 3 key investigations to perform in a suspected haemothorax?

A
  1. CXR
  2. FAST scan
  3. CT scan
32
Q

What will a chest x-ray show in haemothorax and when will this appear?

A

classicla fluid level, but taes approx 500ml of blood to obliterate the costophrenic angle

33
Q

When will haemothorax be particularly difficult to diagnose from CXR?

A

on supine trauma CXR with no fluid level, as blood lies on the posterior chest wall causing diffuse opacification of the hemithorax

34
Q

What is the benefit of a FAST scan for haemothorax?

A

emergency ultrasound, may detect fluid/ haemothorax above the diaphragm on upper quadrant views, but is difficult in presence of pneumothorax or subcutaneous emphysema

35
Q

When can an emergency CT scan be performed to help diagnose haemothorax?

A

in haemodynamically stable patients

36
Q

What is the recommended management of sub-clinical tiny haemothoraces detectable only on CT?

A

usually require no further action, but need follow up CXR to ensure no further expansion

37
Q

What are 5 aspects of management of haemothoraces?

A
  1. Oxygen, emergency IV access x2 and send blood for cross-match
  2. Commence infusion of crystalloid or O-negative blood if patient hypotensive, using boluses of 250ml until patient has SBP >90 mmHg
  3. Chest drain insertion: >32 Fr for adults in order to drain blood from pleural cavity without clotting
  4. Thoracotomy may be indicated if chest tube output >1500ml state or >200ml/h
  5. Urgent cardiothoracic referral
38
Q

What are the 4 key aspects of management of haemothoraces during the ABCDE assessment?

A
  1. Oxygen
  2. Emergency IV access x2
  3. Send blood for cross-match
  4. Commence infusion of crystlaloid or O-negative blood if hypotensive
39
Q

If a patient with a haemothorax is hypotensive, how should crystalloid fluid or o-negative blood be given?

A

boluses of 250ml until systolic BP >90

40
Q

After blood has been drained from a chest drain in haemothorax using a chest drain, what next step should be considered?

A

autotransfusion

41
Q

In what 2 situations may thoracoctomy be indicated in haemothorax management?

A
  1. If chest tube output >1500ml stat
  2. if chest tube output is >200ml/hour
42
Q

What are 2 possible complications of haemothorax?

A
  1. Hypovolaemic shock and death
  2. Empyema from infected retained blood or non-sterile chest drain insertion
43
Q

Why must IV access be obtained before a chest drain is inserted in haemothoraces?

A

sudden decompression may result in haemodynamic collapse and inability to identify access

AIP: Trauma (20 decks)

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