Conservative Management of Hemothorax with Presentation of an Illustrative Case

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The diagnosis of hemothorax may be obvious in case of external Injuries, or difficult to detect when concealed. Should the symptoms, physical examination and x-ray suggest a hemothorax, diagnostic aspiration is necessary for confirmation. Early shock is the rule. Anoxia also supervenes early. The shock is caused by local injury and hemorrhage. Early in shock, local pain and nervous factors are significant. Pallor; rapid, shallow breathing; small, rapid pulse; cyanosis, fall of blood pressure; and apathy appear In proportion to the amount and rapidity of the bleeding. With the loss of blood, there is a feeling of faintness, air hunger, rapid heart action, and coldness of the extremities. Blood volume, red blood count, and hemoglobin are reduced. At first the blood pressure is usually well maintained, but later falls. Cyanosis may not be evident, since it depends upon the grams of reduced hemoglobin present. A sequence of events follows the accumulation of fluid or air in the pleural space. First, there is collapse of the lung on the side of the bleeding. The extent depends upon the presence of adhesions and of the amount of thickening of the pleura. Continuous bleeding builds up pressure, which is exerted against the mediastinum. Unless the mediastinum is firm, it readily shifts to the opposite side and partial collapse of that lung takes place. Local stasis results from pressure upon the great vessels and heart. Since the pulmonary system has a pre$sure one fifth that of the general circulation, control of bleeding from this source is easier; however, the constant movement of the lung may aggravate the bleeding. A vessel from the systemic circulation tends to bleed more violently because of its higher pressure. With increased intrapleural pressure, there is increasing dyspnea and cough, often with expiratory grunt. It is known that with gross hemorrhage rales appear on the side opposite the bleeding. This transudation of fluid across the epithelial surface is the result of pressure upon the heart and great vessels, reduced oxygen supply to tissues, and dilution of the blood plasma with reduction in the osmotic pressure. The most sIgnificant physical signs associated with accumulation of blood are absent breath sounds and dullness to flatness on per