Abstract Introduction Spontaneous hemothorax is defined as the accumulation of blood within the pleural cavity in the absence of antecedent trauma or iatrogenic injury. While large pleural effusions are frequently encountered in the intensive care unit, spontaneous hemothorax accounts for fewer than 5% of such cases. Rapid intrapleural bleeding can cause life-threatening hemodynamic compromise and, in rare instances, develop tension physiology. We report a case of multifactorial shock caused by the coexistence of nontraumatic tension hemothorax and hemorrhagic shock as the initial manifestation of lung adenocarcinoma in a patient receiving apixaban. Case Description A 67-year-old man with chronic kidney disease, dilated cardiomyopathy, and a left ventricular thrombus on apixaban presented with one week of progressive dyspnea and acute confusion. On arrival, he was profoundly hypoxic and hypotensive. Chest radiography demonstrated a massive right pleural effusion with near-complete lung collapse. Laboratory testing showed anemia (hemoglobin 10.2 g/dL) with normal coagulation parameters. Despite fluid resuscitation and oxygen supplementation, hypoxemia and hypotension persisted, necessitating endotracheal intubation. Because of inadequate ventilation and suspected tension hydropneumothorax, a right chest tube was inserted, draining 1 L of frankly bloody fluid. The patient’s hemoglobin rapidly declined to 6.5 g/dL, prompting transfusion of packed red blood cells, platelets, and plasma, along with administration of andexanet alfa for apixaban reversal. Shortly thereafter, he developed cardiac arrest secondary to recurrent tension physiology from rapid reaccumulation of pleural blood. The chest tube was unclamped, cardiopulmonary resuscitation and transfusion were performed, and return of spontaneous circulation was achieved. Computed tomographic angiography showed no active extravasation, and bronchoscopy revealed no endobronchial bleeding source. Following continued transfusion and drainage, hemodynamic stability was restored. Cytologic analysis of the pleural fluid subsequently confirmed lung adenocarcinoma, considered the underlying cause of spontaneous bleeding in the setting of anticoagulation. Discussion This case highlights an exceptionally rare presentation of spontaneous tension hemothorax associated with dual shock physiology—both hypovolemic and obstructive. Early recognition of this dynamic process and timely coordination of drainage control, transfusion, and anticoagulant reversal were lifesaving. Moreover, the eventual diagnosis of lung adenocarcinoma underscores that spontaneous hemothorax, even in anticoagulated patients, warrants thorough evaluation for occult malignancy. This abstract is funded by: None
Corpuz et al. (Fri,) studied this question.