Zeiler Jacob, Idell Steven, Norwood Scott, Cook Alan
Department of Family Medicine, University of Texas (UT) Health Science Center at Tyler, Tyler, TX.
School of Medical Biological Sciences, UT Health Science Center at Tyler, Tyler, TX.
Clin Pulm Med. 2020 Jan;27(1):1-12. doi: 10.1097/CPM.0000000000000343. Epub 2020 Jan 10.
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs. If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
血胸是指胸腔内积血，通常由外伤引起。历史上，胸部X线一直是患者入院后首选的影像学检查方式。床旁超声，特别是通过创伤超声重点评估扩展方案（eFAST）的敏感性和特异性已经足够高，足以使其在大多数一级创伤中心作为X线片的辅助检查手段。如果血胸的大小或严重程度需要干预，胸腔闭式引流术一直是且仍然是首选的治疗方法。大多数血胸病例通过胸腔闭式引流术可以治愈。如果胸腔闭式引流术后胸腔内仍有残留血液，则被认为是存留血胸，有发生脓胸和纤维胸等晚期并发症的重大风险。一旦发生晚期并发症，发病率和死亡率会急剧增加，唯一的确定性治疗方法是手术。为了避免手术，研究一直集中在在存留血胸发生病理进展之前将其清除。最有前景的治疗方法是将纤溶药物注入胸腔，分解血胸，以便进一步引流。虽然已经取得了重大进展，但仍需要进一步试验来进一步确定纤溶药物在这种情况下的剂量和药代动力学。如果内科治疗和早期手术未能解决存留血胸问题，通常需要进行手术。历史上手术仅包括开胸手术，但在非紧急情况下，已 largely 被电视辅助胸腔镜手术（VATS）取代，这是一种微创技术，在患者术后恢复和疼痛方面有显著改善。如果所有先前解决血胸的尝试均失败，则可能需要进行开胸手术。
