What are the causes of a haemothorax?
In this case the cause is related to the recently drawn chest tube that is iatrogenic. Other causes include: spontaneous pneumothorax, coagulopathy, vascular disorders e.g aneurysms or arteriovenous malformations, neoplasia, miscellaneous causes e.g. costal exostoses, extramedullary hematopoesis, endometriosis etc. Blunt chest trauma as the most common cause of haemothorax does not apply for this case.
What are the treatment options of haemothorax?
Treatment options: Chest tube drainage: is seen as an adequate initial approach for most cases unless the patient is unstable or aortic dissection or aortic rupture is suspected. Surgical approach: According to the literature blood loss by chest tube 1.500 ml in 24 h or 200 ml per hour during several successive hours are criteria for VATS or thoracotomy, depending on hemodynamic stability.
How does the chest CT help in this case?
The CT shows that the above-stated criteria are easily met and helps in the localization of an active bleeding site. In this case, the thoracic surgeon felt, that the patient was stable enough for the VATS approach and the later hospital course proved him right.
- massive amount of inhomogeneous, high-density fluid (25-60HU) in the right pleural cavity, consistent with intrathoracic haemorrhage
- ipsilateral lung compression (collapse of the upper, lower, and middle lobe)
- displacement of the trachea, mediastinum and the heart to the left side
- compression of the right brachiocephalic vein and the superior vena cava (SVC) with abundant venous collaterals
- three punctate foci of contrast extravasation extending from the anterolateral 4th intercostal space (at the site of the previously inserted and drawn chest tube) into the right pleural cavity suggesting the bleeding source
- soft tissue swelling and chest wall emphysema caudolaterally
Additional Findings:
- central venous catheter via the left internal jugular vein (IJV) with tip straight (not ideal) in the distal part of the vessel
- status post segmental resection of the left upper lobe (superior division and lingula)
- status post gastrectomy and splenectomy