A 19-Year-Old Shooting Victim With Complications

Janice Verham, MD

Disclosures

July 08, 2019

Discussion

The differential diagnosis in this patient was initially broad, after a chief complaint of pleuritic chest pain associated with shortness of breath, tachypnea, and tachycardia. However, the patient's acutely worsening anemia and chest radiography provided a clear diagnosis of hemothorax.

Hemothorax is an accumulation of blood in the pleural space, which may occur spontaneously or secondary to blunt or penetrating trauma. Injured lung parenchyma from fractured ribs is the main cause of bleeding from blunt trauma; however, in rare cases, injury to the intercostal arteries, cardiac injury, and pulmonary hilar are sources of bleeding that should be considered.

The source of bleeding is important because it guides the physician as to how to manage the bleeding. For example, lung parenchyma often stop bleeding without additional intervention, whereas bleeding from the pressurized arterial system (eg, lacerated intercostal arteries) often requires intervention.[1]

Spontaneous hemothorax may also occur, although it is significantly less common. Causes of spontaneous hemothorax include rupture of pleural adhesions, neoplasms, metastasis, and systemic anticoagulant therapy.[2] Because spontaneous causes are less likely, a thorough work-up for chest pain and/or shortness of breath is always indicated.

Physical examination findings for hemothorax may include absent or decreased breath sounds. With the assistance of imaging, a tracheal deviation, blunting of the costophrenic angle, or complete opacification of the pleural cavity may be visualized. However, a hemothorax is usually not visible on a chest x-ray until a minimum of 200 mL of fluid is present in the pleural cavity. With a smaller fluid collection, lateral chest radiography is indicated because that view allows visualization of smaller collections.[3] CT is frequently used owing to its higher sensitivity compared with chest radiography in diagnosing hemothorax.[4]

Ultrasonography is increasingly used as part of the evaluation for hemothorax; a Focused Assessment with Sonography in Trauma (FAST) scan is widely considered the criterion standard for an initial trauma evaluation and is as sensitive and specific as chest radiography.[5,6] Given that ultrasonography may already be part of the trauma team evaluation, its use can save time in the workup and diagnosis of hemothorax.

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