The treatment of a<unk>  depends largely on the extent of bleeding. While small<unk> es may require little in the way of treatment, larger<unk> es may require fluid resuscitation to replace the blood that has been lost, drainage of the blood within the pleural space using a procedure known as a tube thoracostomy, and potentially surgery in the form of a thoracotomy or video-assisted thoracoscopic surgery (VATS) to prevent further bleeding. Occasionally, transcatheter arterial embolization may be used to stop ongoing arterial bleeding. Additional treatment options include antibiotics to reduce the risk of infection and fibrinolytic therapy to break down clotted blood within the pleural space. Thoracostomy A tube thoracostomy unit Blood in the cavity can be removed by inserting a drain (chest tube) in a procedure called a tube thoracostomy. This procedure is indicated for most causes of<unk> , but should be avoided in aortic rupture which should be managed with immediate surgery. The thoracostomy tube is usually placed between the ribs in the sixth or seventh intercostal space at the mid-axillary line. It is important to avoid a chest tube becoming obstructed by clotted blood as obstruction prevents adequate drainage of the pleural space. Clotting occurs as the clotting cascade is activated when the blood leaves the blood vessels and comes into contact with the pleural surface, injured lung or chest wall, or the thoracostomy tube. Inadequate drainage may lead to a retained<unk> , increasing the risk of infection within the pleural space (empyema) or the formation of scar tissue (fibrothorax). Thoracostomy tubes with a diameter of 24–36 F (large-bore tubes) should be used, as these reduce the risk of blood clots obstructing the tube. Manual manipulation of chest tubes (referred to as milking, stripping, or tapping) is commonly performed to maintain an open tube, but no conclusive evidence has demonstrated that this improves drainage. If a chest tube does become obstructed, the tube can be cleared using open or closed techniques. Tubes should be removed as soon as drainage has stopped, as prolonged tube placement increases the risk of empyema.<unk>  mid-VATS showing diaphragmatic injury caused by a costal exostosis<unk>  mid-thoracotomy showing bleeding from tears in the pulmonary ligament and no other obvious injuries. Surgery About 10–20% of traumatic<unk> es require surgical management. Larger<unk> es, or those that continue to bleed following drainage, may require surgery. This surgery may take the form of a traditional open-chest procedure (a thoracotomy), but may be performed using video-associated thoracoscopic surgery (VATS). While there is no universally accepted cutoff for the volume of blood loss required before surgery is indicated, generally accepted indications include more than 1500 mL of blood drained from a thoracostomy, bleeding rate of over 500mL/hr in the first hour followed by over 200 mL, hemodynamic instability, or the need for repeat blood transfusions. VATS is less invasive and cheaper than an open thoracotomy, and can reduce the length of hospital stay, but a thoracotomy may be preferred when hypovolemic shock is present, in order to watch bleeding. The procedure should ideally be performed within 72 hours of the injury as delay may increase the risk of complications. In clotted<unk> , VATS is the generally preferred procedure to remove the clot, and is indicated if the<unk>  fills 1/3 or more of a<unk> . The ideal time to remove a clot using VATS is at 48–96 hours, but can be attempted up to nine days after the injury. Other Thoracentesis is no longer used in the treatment of<unk> , although it may still be used to treat small<unk> es. In catamenial<unk> , the bleeding is typically self-limiting and mild. Most people with the condition are stable and can be treated with hormonal therapies. They are only partially effective. Surgical removal of the endometrial tissue may be necessary in recurrent cases. However, the disease frequently recurs. Resuscitation with intravenous fluids or with blood products may be required. In fulminant cases, transfusions may be administered before admission to the hospital. Clotting abnormalities, such as those caused by anticoagulant medications, should be reversed. Prophylactic antibiotics are given for 24 hours in the case of trauma. Blood clots may be retained within the pleural cavity despite chest tube drainage. They are a risk factor for complications like fibrothorax and empyema. Such retained clots should be removed, preferably with video-assisted thoracoscopic surgery (VATS). If VATS is unavailable, an alternative is fibrinolytic therapy such as streptokinase or urokinase given directly into the pleural space seven to ten days after the injury. The issues with fibrinolytic therapy include having a high cost and lengthened hospital stay. Residual clot that does not dissipate in response to fibrinolytics may require surgical removal in the form of decortication.
Hemothorax
Pneumothorax
Urinothorax
Traumatic cardiac arrest
Chylothorax
Pulmonary hematoma
Hydropneumothorax
Hemopneumothorax