The management of occult hemothorax in adults with thoracic trauma: A systematic review and meta-analysis

Abstract

BACKGROUND Hemothorax is a common sequelae following thoracic trauma and is associated with significant morbidity and mortality. Current guidelines recommend all traumatic hemothoraces be considered for drainage with tube thoracostomy (TT), regardless of size. With increasing use of computed tomography, smaller hemothoraces not seen on x-ray (defined as an occult hemothorax) are frequently detected. METHODS This systematic review was performed to gather data on patients with occult hemothorax managed with TT or without TT (termed expectant management [EM]). MEDLINE, EMBASE, and Cochrane databases from inception to October 2019 were searched for relevant articles. The primary outcome was rates of failure of expectant (conservative) management. Secondary outcomes of interest included predictors of TT insertion, predictors of failure of EM, and morbidity and mortality in patients with occult hemothorax. RESULTS We screened 1,329 abstracts from which 6 articles reporting 1,405 patients with occult hemothorax were included. Of these patients, 601 (43.68%) were managed initially with TT, and 802 (56.32%) were managed expectantly. Of the 802 patients managed expectantly, 212 failed conservative management and underwent TT insertion (23.1% pooled failure rate estimate [95% confidence interval, 17.1–29.1%]). The presence of concomitant pneumothorax predicted upfront TT insertion. Of the patients who failed EM, the need for mechanical ventilation and the presence of a large hemothorax predicted failure. Mortality was similar in both groups. CONCLUSIONS Conservative treatment of occult hemothorax fails in 23.1% of patients. The presence of hemothorax greater than 300 mL and the need for mechanical ventilation predicted failure of conservative treatment and the need for TT. There was no difference in mortality between EM and TT cohorts. These data suggest that it may be possible to safely observe patients with occult hemothoraces less than 300 mL (1.5 cm pleural stripe) secondary to blunt trauma without upfront TT insertion. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.

Chest Tube Placement in Mechanically Ventilated Trauma Patients: Differences between Computed Tomography-Based Indication and Clinical Decision

“…This is in contrast to another study that identified displaced rib fractures and moderate-sized pneumothorax as significant factors associated with chest tube placement in patients with blunt chest trauma and occult pneumothorax [ 28 ]. In another study, the conservative treatment of occult hemothorax failed in about 23% of patients, in which hemothorax volumes of more than 300 mL and the need for mechanical ventilation had the highest predictive value for chest tube placement [ 29 ]. However, a conservative approach to occult pneumothorax detected only on CT can be a safe procedure, even for mechanically ventilated patients [ 11 , 30 ].…”

A masszív haemothorax modern kezelése

“…Az úgy-nevezett spontán haemothorax jóval ritkább, ennek számos oka van: többek között malignus mellüregi folyamat, pleuralis összenövések elszakadása, tüdőembolia antikoaguláns kezelése, Ehlers-Danlos-szindróma, neurofibromatosis miatt spontán rupturált arteria (a.) intercostalis vagy a. mammaria, az a. pulmonalis malformációi (Rendu-Osler-Weber-szindróma), endometriosis, exostosis, thrombocytagátló kezelés kisiklásának következménye [1][2][3].…”

“…Általános irányelvként, amennyiben a drénen ürülő vér mennyisége meghaladja az óránkénti 200 ml-t 3-4 órán keresztül a csövezést követően, vagy több mint 1500 ml vér ürül 24 óra alatt, és a keringés stabilitása transzfúzióra szorul, műtét javasolt [1][2][3][4][5][6][7][8][9][10][11]. A döntést azonban befolyásolják az aktuális körülmények, a beteg általános állapota, a BMI, a társbetegségek.…”

“…A haemothorax a legtöbbször baleset következménye, ezek között is élen jár a közlekedési balesetek következtében kialakuló politraumához társuló haemothorax [1][2][3][4][5][6]. A többszörös bordatörést követő vérmell diagnosztikája diagnosztikus thoracocentesis, de a sürgősségi drenázs is egyben diagnosztikus és terápiás beavatkozás.…”

“…Súlyos esetekben a vérmell elsődleges ellátásában a "dam age control" elvei irányadóak [18]. Irányadásra jó adat, de eseti mérlegelést igényel a mellkascsövön keresztül ürülő friss vér mennyisége: ha meghaladja az 1500 ml-t, vagy az óránként ürülő volumen 200 ml feletti, a sürgősségi thoracotomia az ajánlott eljárás [1][2][3][4][5][6][7][8][9][10][11].…”