HAEMOTHORAX AND HAEMOPNEUMOTHORAX

HAEMOTHORAX Aspirate a patient’s chest on the suspicion that there might be blood in it. If necessary, aspirate on both sides. If you find blood, insert an intercostal drain with an underwater seal bottle (65.2), on both sides if necessary. Leave the tube in until bleeding stops.

Replace the blood that he loses by transfusing an equal volume.

Examine his lungs several times daily. If drainage is successful, his breath sounds will gradually reappear and increase in strength. His pulse rate should fall and his blood pressure should rise.

If a patient’s intercostal drain becomes blocked, reinsert it.

If his lungs fail to expand, refer him for decortication as soon as possible. The earlier you do this the easier the operation will be. If possible, refer him within 3 days.

HAEMOPNEUMOTHORAX Blood and air form a froth in the pleural cavity. Some blood will drain through a catheter inserted high up anteriorly. But you will usually need to insert a second one for blood lower down posteriorly. One tube may be enough; two tubes are better. If you decide to rely on a single tube, cut side holes in it and push it well up inside the pleural cavity.

DIFFICULTIES WITH BLOOD OR AIR IN THE CHEST

IF EARLY ASPIRATION FAILS TO WITHDRAW BLOOD, don’t be put off. If you think blood is present, insert a drain. Sometimes the blood clots in the first few hours, after which the clot liquifies again before it finally organises a few days later. If the haemothorax is a large one, and clots continually block the tube, a thoracotomy may be necessary, so refer the patient rapidly.

If this is impractical, try resetting a rib and inserting an open drain (6.1).

If a patient has a severe chest injury and FAILS TO IMPROVE, (his pulse does not fall and his blood pressure does not rise), consider these possibilities:

(1) Has he any other injuries? X-ray him. You may see: (a) Broadening of his mediastinum suggesting an injury to his aorta. (b) The contents of his abdomen in his pleural cavity. (c) Patchy consolidation in one or both lung fields (’wet lung’). (2)Does he have an abdominal injury? Try peritoneal lavage (66.1). It will not interfere with treatment of his chest injury.

If you are in any doubt, don’t postpone laparotomy.

If BLOOD CONTINUES TO DRAIN from his pleural cavity, a large vessel has probably been injured, perhaps in his lung. Fortunately, this is rare. Replace blood as it is lost. If more than 500 ml drains during the second hour, thoracotomy is indicated. This is fortunately only necessary in about 5% of cases. If you can refer him for a thoracotomy, do so early.

If his HAEMOTHORAX BECOMES infected, treat it as an empyema (6.1).

Figure 65.8: SOME MORE CHEST METHODS. A, B, and C, an emergency one way valve made from the finger of an old glove. D, to G, a method of making sure a chest drain is not pulled out. Cut nicks in two pieces of strapping, lay them round the tube, and overlap them. Stick two narrower pieces of strapping on top of them and twist these round the tube. H, to J, if you don’t have a 3-way tap, drain the chest like this. Tie a piece of tube to two needles, aspirate the chest, and clamp the tube while you discharge the syringe. Kindly contributed by Peter Bewes and James Cairns.