Spontaneous tension haemopneumothorax
© Patterson et al; licensee BioMed Central Ltd. 2008
Received: 27 October 2008
Accepted: 31 October 2008
Published: 31 October 2008
We present a patient with sudden onset progressive shortness of breath and no history of trauma, who rapidly became haemodynamically compromised with a pneumothorax and pleural effusion seen on chest radiograph. He was treated for spontaneous tension pneumothorax but this was soon revealed to be a tension haemopneumothorax. He underwent urgent thoracotomy after persistent bleeding to explore an apical vascular abnormality seen on CT scanning. To our knowledge this is the first such case reported.
Aetiology and current approach to spontaneous haemothorax are discussed briefly.
Spontaneous haemopneumothorax (SHP) occurs in 1–12% cases of spontaneous pneumothorax and is characterised by spontaneous pneumothorax with over 400 mls of blood in the pleural cavity . This can go unnoticed or can cause life threatening hypovolaemia.
We could find no reports of spontaneous tension haemopneumothorax in the literature, as defined by a pubmed search using the keywords and MeSH terms "spontaneous haemothorax" and/or "tension pneumothorax". Here SHP is discussed as the underlying pathological process is the same. In a recent review of the management of 211 cases of SHP, it is a described as a condition affecting mostly young men with three main causes. These are bleeding from a torn adhesion between the pleura, rupture of a vascularised bulla or an aberrant apical vessel associated with a bulla that ruptures . Treatment depends on clinical condition and facilities available. A third of patients in the series were shocked and needed urgent surgery, and in a further third it was clear that immediate operation for haemostasis would be required. However nine out of ten patients would eventually need surgery, and indications for delayed surgery were persistent air leak and clot evacuation. Of those having surgery 43% had a video assisted thoracoscopic surgical (VATS) procedure which was definitive, and 45% required a thoracotomy. Post operative results are good with no major complications and no recurrence. The remaining patients were treated conservatively having none of the above indications for surgery. In a small series of nine such cases with mean blood loss of 1533 mls, it was successful in seven but with two needed a thoracotomy due to worsening clinical condition . This author suggests that if bleeding persists for less than 24 hours then conservative treatment is adequate. In a report of four cases of spontaneous tension pneumothorax the diagnosis was made radiologically rather than clinically on every occasion, and in each case the clinicians were not aware that it this could happen . No reports exist of spontaneous pneumothorax presenting under tension.
Spontaneous tension pneumothorax is very rare, but requires treatment in the same manner as one of any other aetiology. This may also be associated with haemothorax which could be apparent radiologically, or during the course of treatment with an intercostal drain. These patients may develop hypovolaemic shock and most with clinically obvious bleeding require operative intervention. If the patients vital signs are stable enough they should have a CT scan to look for a bleeding point and be observed in an environment where thoracic surgeons can be called upon for assistance. If operation is not required in the first 24 hours then the chances of needing surgery are reduced.
Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal
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