What is the diagnosis, signs, symptoms, and treatment of hemothorax in the Cardiovascular Intensive Care Unit (CVICU)?

Hemothorax in CVICU: Diagnosis, Signs, Symptoms, and Management

Hemothorax is a collection of blood in the pleural cavity that requires prompt recognition and intervention, especially in the CVICU setting where patients may have undergone cardiac surgery or experienced trauma.

Definition and Etiology

• Hemothorax is defined as an accumulation of blood within the pleural space, which can result from traumatic injury, iatrogenic causes, or spontaneous bleeding 1
• In the CVICU, common causes include:
  • Cardiac surgery complications
  • Right atrium rupture at the junction with inferior vena cava 2
  • Pleuropericardial laceration 2
  • Penetrating cardiac injuries 2
  • Complications of central venous access procedures 2

Signs and Symptoms

• Clinical presentation may include:
  • Dyspnea or respiratory distress 1
  • Chest pain 3
  • Hypotension or shock in severe cases 2
  • Decreased breath sounds on the affected side 1
  • Dullness to percussion 1
  • Tachycardia 3
  • Tracheal deviation to the opposite side in large hemothorax 2

Diagnostic Approach

• Imaging studies:

  • Chest X-ray: Initial imaging modality showing opacification of the affected hemithorax 1
  • Point-of-care ultrasound (POCUS): Highly sensitive for detecting pleural fluid; can be performed rapidly at bedside 2
  • CT chest with IV contrast: Recommended to identify the source of bleeding and rule out concomitant cardiovascular injury 2

• Bedside cardiac ultrasonography (BCU):

  • Should be performed in hemodynamically stable patients with penetrating chest trauma 2
  • Can detect pericardial effusion, cardiac tamponade, and cardiac lacerations 2
  • May need to progress to transesophageal echocardiography (TEE) if transthoracic views are suboptimal 2

Management

Immediate Interventions

• For active bleeding with hemodynamic instability:
  • Immediate chest tube placement (large-bore 24F-28F) 4
  • Volume resuscitation with blood products 2
  • Correction of coagulopathy if present 2
  • Consideration of emergency thoracotomy for massive bleeding 5

Chest Tube Management

• Connect chest tube to a water seal device with suction to help re-expand the lung 4
• Monitor drainage output closely - significant ongoing output (>200 ml/hr) suggests need for surgical intervention 3
• Avoid clamping the chest tube in the presence of an active air leak to prevent tension pneumothorax 4

Surgical Intervention Criteria

• Immediate surgical exploration is indicated if:
  • Initial drainage >1,500 ml of blood 3
  • Ongoing blood loss >200 ml/hour 3
  • Hemodynamic instability despite resuscitation 5
  • Evidence of cardiac or major vascular injury 2

Management of Retained Hemothorax

• If blood remains in the pleural space after tube thoracostomy (retained hemothorax):
  • Consider intrapleural fibrinolytic therapy to break down clots and adhesions 1, 3
  • Video-assisted thoracoscopic surgery (VATS) for evacuation if fibrinolytics fail 1
  • Open thoracotomy may be required for complex cases or if VATS is unsuccessful 1

CVICU-Specific Considerations

• Post-cardiac surgery patients:

  • Monitor for hemothorax after procedures involving the heart or great vessels 2
  • Be vigilant for hemothorax associated with pleuropericardial laceration 2
  • Consider cardiac chamber rupture in patients with unexplained hemothorax after cardiac surgery 2

• Central venous catheter-related:

  • Upper body insertion sites (subclavian, internal jugular) are preferred over femoral sites to minimize infection risk but may increase risk of pneumothorax or hemothorax 2
  • Ultrasound guidance for central line placement significantly reduces the risk of hemothorax 2

• Anticoagulation management:

  • Carefully balance the risk of thrombosis versus continued bleeding 2
  • Consider reversal agents in life-threatening hemorrhage 2
  • Resume anticoagulation only after bleeding is controlled 2

Complications and Prevention

• Potential complications of untreated or inadequately treated hemothorax:

  • Empyema (infected pleural space) 1
  • Fibrothorax (trapped lung) 1
  • Respiratory compromise 1

• Prevention strategies in CVICU:

  • Ultrasound guidance for all central line placements 2
  • Careful technique during cardiac procedures 2
  • Prompt recognition and management of coagulopathies 2
  • Serial chest radiographs to monitor for early signs of hemothorax 4

Timing Considerations

• Delayed drainage (>24 hours after injury) increases the likelihood of requiring surgery or thrombolytic therapy 6
• Drainage performed after post-injury day 5 is more likely to require surgical intervention 6
• Early detection and drainage are essential to prevent complications 6