In this specific case, the cause of hemothorax was unique because it was attributed to intrathoracic tPA administration for a loculated pleural effusion. Intrathoracic hemorrhage is a rare but acknowledged complication of tPA administration. The patient had a prior hemothorax secondary to multiple rib fractures, which may have increased his risk for bleeding.
A case report found that a patient with previous rib fractures developed a hemothorax after fibrinolytic therapy for empyema that required two thoracotomies. This suggests that clinicians should have an increased awareness when using fibrinolytic therapy in the setting of recent trauma. In addition, patients receiving therapeutic anticoagulation, or who are coagulopathic from other causes (including liver disease) at the time of intrapleural fibrinolytic therapy, may be at increased risk for pleural hemorrhages.
After diagnosis of a hemothorax, the next logical step is determining the proper management. Tube thoracostomy (chest tube) is the placement of a tube to drain air or fluid from the pleural cavity. Placement of a chest tube may be performed via the Seldinger technique or a classic surgical technique, which is used more often in a trauma setting. The size of chest tube is measured in the unit French (Fr), which is equivalent to 0.33 mm and refers to the diameter of the outside of a cylindrical tube.
The optimal chest tube size has been thoroughly studied, with recent data suggesting that use of large-bore (> 14 Fr) chest tubes is not correlated with improved outcomes. The use of smaller-caliber catheters is associated with decreased pain and lower risk for damage to surrounding structures. Although many physicians still advocate for the insertion of a large-bore (32-40 Fr) chest tube for acute hemothorax, a study by the trauma group at University of Arizona suggests that use of 14-Fr pigtail catheters had higher drainage output and decreased the number of days with a chest tube in place, without an increased rate of failed attempts or complications related to tube insertion.
Although it is debated, most physicians drain the pleural cavity via placement of a chest tube if the hemothorax is > 500 mL. Massive hemothorax, which is defined as > 1500 mL or > 200 mL/hr for 2-4 hours in the pleural space, typically occurs in trauma patients. The source of the bleeding in massive hemothorax is either a pulmonary vascular or an arterial source. Because neither cause is likely to stop without additional intervention, operative exploration is the criterion standard.
Complications of chest tube thoracostomy include infection, empyema, and lung injury; the incidence rate of other, more rare complications is reportedly as high as 20%. Algorithms are useful in guiding treatment once a chest tube is placed.
Infectious complications, including empyema and pneumonia, are the most common complications after chest tube drainage of hemothorax. Although some providers use prophylactic antibiotics, this practice is highly controversial because large-scale reviews suggest insufficient evidence to support this routine practice. Other systematic reviews suggest a decreased risk for empyema and infectious complications with antibiotic prophylaxis in patients with penetrating chest injuries, but not in those with blunt chest trauma.
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