[The diagnostic dilemma of acute thoracic pain]

Acute aortic dissection is gaining recognition in Western societies, and is being diagnosed with increasing frequency. New diagnostic imaging modalities, longer life expectancy in general, as well as the increase in the number of hypertension patients have all contributed to the growing awareness of aortic dissections. Compared with acute coronary syndrome and lung embolism, aortic dissection is among the most frequently diagnosed life-threatening conditions involving chest pain. Here we report the case of a 59 year old patient suffering from hypertension and discuss the latest diagnostic and therapeutic procedures in the setting of acute chest pain.

Aortic rupture: comparison of three imaging modalities

We report a case of a 56-year-old man with traumatic aortic rupture (TAR) sustained in a motor vehicle accident diagnosed by helical computed tomography, aortography, and transesophageal echocardiography. A large majority of patients with TAR never make it to the hospital, and for those who do, a timely diagnosis is critical for survival. We discuss the merits and pitfalls of the three imaging modalities.

Imaging of penetrating chest trauma

This article discusses the role of imaging in evaluating patients who are admitted with penetrating injuries to the chest. Emphasis is placed on the role of multidetector row CT, which has been introduced in the past 5 years into the arena of care for trauma victims. It is important to take full advantage of this new CT technology with its capability to produce high-resolution multiplanar and volumetric images to diagnose penetrating chest injuries. This article emphasizes detection of active bleeding and assessment of the mediastinum for penetrating injury.

Tension empyema as a reversible cause for cardiac arrest

Empyema is a well recognised complication of pneumonia.1 We report a case of pulseless electrical activity (PEA) treated in the emergency department (ED) with intercostal tube drainage based on clinical findings, where a tension empyema was found to be the cause. To our knowledge, this is the first report of actual cardiac arrest from this cause.

Massive hemothorax in a beta-thalassemic patient due to spontaneous rupture of extramedullary hematopoietic masses: diagnosis and successful treatment

Intrathoracic extramedullary hematopoiesis is an unusual but well-described entity. The condition is typically found in patients who have chronic hemolytic anemias, especially thalassemia. We report a case of a 38-year-old man with underlying beta thalassemia/hemoglobin E who developed intrathoracic extramedullary hematopoiesis. The hematopoietic masses spontaneously ruptured, resulting in massive hemothorax. The condition was confirmed by video-assisted thoracoscopy and successfully treated with surgery, hydroxyurea, and radiation.

[Video-thoracoscopy in the treatment of patients with penetrating wound of the thorax]

Thoracoscopic surgical procedures were used in the treatment of 79 patients with penetrating wound of the thorax complicated by hemothorax. Small hemothorax was diagnosed in 72.1% patients; 56.1% had injuries of thoracic organs, 26.3% -- injuries of diaphragm. Thoracoscopic hemostasis and correction of intrathoracic injuries were performed in 84,6% patients. Conversion to video-assisted minimally-invasive thoracotomy (because of injuries of the diaphragm as a rule) occurred in 15,8% patients, conversion to typical thoracotomy -- in 3.5%. In medium hemothorax (16.4% patients) injuries of thoracic organs and anatomic structures were diagnosed in 76.9% cases. Hemostasis and correction of intrathoracic injuries through thoracoscopic approach were performed in 43.8% patients, conversion to typical thoracotomy was necessary in 7% cases. Big hemothorax was diagnosed in 11.4% patients, 55.6% of them had injuries of thoracic organs and anatomic structures. Complete thoracoscopic procedure was performed in 44.4% cases; 33.3 patients required conversion to thoracotomy. Thoracoscopy is an effective method of surgical treatment of thoracic injuries in patients who don't require urgent thoracotomy. This procedure permits repair of intrathoracic injuries in 73.4% cases. Postoperative complications were seen in 15% cases, postoperative lethality was 1.4%.

Spontaneous Hemothorax After Caesarian Section: An Unusual Manifestation of Diaphragmatic Fenestrations

Spontaneous hemothorax is an uncommon condition usually associated with trauma, iatrogenic interventions, or rupture of pleural adhesions, and pneumothorax. We report the unique case of spontaneous hemothorax in a 35-year-old woman resulting from uterine hemorrhage in whom fenestrations in the diaphragm allowed blood to pass from the abdomen to the chest.

Endovascular Treatment of a Ruptured Internal Thoracic Artery Pseudoaneurysm Presenting as a Massive Hemothorax in a Patient with Type I Neurofibromatosis

We report a case of acute hemothorax caused by a left internal thoracic artery pseudoaneurysm rupture in a patient with neurofibromatosis type I, which was successfully treated with endovascular coil embolization.

Costal osteochondroma presenting as haemothorax and diaphragmatic laceration

We report the unusual case of an 11-year-old girl who suffered a large haemothorax and lacerated left hemidiaphragm because of a costal osteochondroma arising from the left sixth rib near the costochondral junction. Surgical excision of the osteochondroma was performed and the lacerated diaphragm was repaired.

Thoracic trauma: the deadly dozen

Deadly Dozen ... Lethal Six ... Hidden Six ... Major thoracic injuries are known as the Deadly Dozen. The Lethal Six (airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive hemothorax, and flail chest) are immediate, life-threatening injuries that require evaluation and treatment during primary survey. The Hidden Six (thoracic aortic disruption, tracheobronchial disruption, myocardial contusion, traumatic diaphragmatic tear, esophageal disruption, and pulmonary contusion) are potentially life-threatening injuries that should be detected during secondary survey. Each of these may present as immediately life-threatening or potentially life-threatening events. This article provides an overview of these 12 injuries and appropriate management for each. Case studies are included.

Thoracic aortic pseudoaneurysm after spine trauma in ankylosing spondylitis. Case report

Ankylosing spondylitis (AS) is a rheumatic disease characterized by consolidation of the articulating surfaces and inflammation of the vertebral column. Because of its associated spine stiffness and secondary osteoporosis, patients with this disorder are at increased risk of vertebral fractures. Ankylosing spondylitis presents a significant challenge to spine surgeons because of its complex effects on the spine, extraarticular organ manifestations, and potential neurological and functional sequelae. Traumatic thoracic and lumbar spine injuries in this patient population may be associated with injury to the aorta either due to direct mechanical trauma or to blunt forces associated with the spine fracture. This complication and association is thought to be the result of pathophysiological changes that cause the aorta to become firmly adherent to the anterior longitudinal ligament. The authors present a case of AS in a patient with a thoracic spine fracture and in whom a delayed thoracic aortic pseudoaneurysm ruptured. To the best of the authors' knowledge, only five cases of this complex condition have been reported since 1980. Recognition of the potential for aortic injury in patients with AS should prompt early investigation of the aorta in cases involving numerous fractures and assist in surgical planning to avoid this lethal injury.

Recurrent catamenial hemothorax

Endometriosis is a common cause of chronic pelvic pain and infertility affecting women of reproductive age, but the disease in rare conditions may be extragenital so may be present with a variety of symptoms. This is a report of an unusual case of pelvic endometriosis that presented with a recurrent hemothorax.

[Diagnostic image (221). A female multitrauma patient]

A 39-year-old woman who was involved in a high-energy trauma suffered a haematopneumothorax, subcutaneous emphysema, multiple fractures including a fracture of corpus Tx, and air in the epidural space.

Hémothorax droit intarissable révélateur d'une plaie hépatique avec rupture diaphragmatique

We report a case of a woman with a blunt thoracic trauma and haemorrhagic shock after a road traffic accident. The clinical and complementary examinations revealed an isolated right haemothorax, which was compressive and uncontrollable. The source of bleeding was discovered with delay and during a surgical exploration: it was a liver injury with diaphragmatic rupture but without hepatic herniation and peritoneal effusion. The diagnostic features of blunt diaphragmatic rupture are discussed.

[Haemothorax and chylothorax: surgical approach]

Diseases causing blood accumulation in the pleural space (or haemothorax) are usually very demanding for diagnosis and require a multidisciplinar therapeutical approach in emergency. So, their treatment should always be immediate and should aim to restore the optimal patient's haemodynamic conditions and to find the site of bleeding. Chylothorax, a lymphatic effusion in the pleural space, is also a very important pathology, as it effects the nutritional and immunological state of the patient causing pleural involvement and respiratory insufficiency. Stabilisation of vital parameters with adequate systemic therapies (blood perfusions, fluids and pro-coagulation factors, TPN) preceeds surgery, which can be the placement of a thoracic drain or emergency thorascopy and/or thoracotomy. The Authors report the casistic of the latest three years for diagnosis and treatment of haemothorax and chylothorax stressing the advantages of a minimal invasive approach for evacuation and identification of the origin of bleeding and haemorrhage and/or lymphatic effusion control.

An adult case of Bochdalek hernia complicated with hemothorax

A 53-year-old female with mild shock due to vomiting and abdominal pain visited the emergency room of our hospital. Chest X-ray on admission showed a large amount of left pleural effusion. Thoracentesis revealed hemorrhagic pleural effusion. An upper gastrointestinal series showed interruption of the upper gastric body, but the anal side was not visualized. Contrast X-ray examination of the thoracic cavity via the drainage tube demonstrated intrathoracic herniation through the diaphragm. These findings suggested gastric impaction in the foramen of Bochdalek, and thoracotomy was immediately performed. A black-colored stomach and greater omentum, suggesting necrotic changes, were observed in the thoracic cavity, and there was bleeding from the greater omentum. Resection of the necrotic organs and closure of the hernial orifice were followed by good recovery.

Ruptured thoracic aortic dissection presenting as opacified left hemothorax

Acute aortic dissections are uncommon, with a reported incidence of 2000 cases per year in the United States. Hemothorax is an unusual but well-described complication of ruptured thoracic aortic dissection. It usually occurs on the left and can be seen in both proximal and distal dissections. Chest radiographs (CXR) in thoracic aortic dissections often reveal a widened mediastinum or abnormal aortic silhouette, evident in 80%-90% of cases. However, CXR may be normal in about 12% of patients with aortic dissection. Clues that would indicate aortic dissection such as abnormal aortic silhouette and widened mediastinum may be obscured by an opacified hemothorax caused by rupture of a thoracic aortic dissection. A high index of suspicion is necessary to make a diagnosis of ruptured thoracic aortic dissection in a patient presenting with hemothorax. This is illustrated in the case described.

Compression of an extracardiac fontan following classic fontan revision

BACKGROUND

The extracardiac Fontan arose as an alternative in order to prevent the classical procedure's sequelea. Complications of the extracardiac Fontan have been described, but this case report aims to highlight the devastating and infrequent complication of external conduit compression.

METHODS AND RESULTS

A 25-year-old male underwent Fontan conversion to extracardiac Fontan for atrial arrhythmias and giant right atrium. He developed postoperative respiratory distress, renal failure, and hemorrhagic pancreatitis, which prompted CT scans of his chest and abdomen that demonstrated external compression of the conduit by mediastinal hematoma. Endovascular stenting restored flow through the conduit, but the patient ultimately expired.

CONCLUSIONS

External Fontan compression, which can be caused by numerous sources, may lead to significant organ dysfunction and can be difficult to recognize despite invasive monitoring. We report this complication and suggest ringed conduits to be considered to avoid the possibility of external compression.

A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma☆

OBJECTIVES

A prospective analysis was conducted to define the incidence of occult pneumothorax (OPX), delayed pneumothorax (DPX) and delayed hemothorax (DHX) and to propose an algorithm for surveillance.

METHODS

During the last 2 years 709 consecutive patients who did not fulfill the indications for intrahospital management were examined at our emergency department for blunt thoracic injury. All patients were subjected to expiration posteroanterior chest radiograph (eCXR) and were scheduled for reevaluation after 24, 48 h and at 7, 14 and 21 days.

RESULTS

OPX was present in 28 patients (4%) detected only with eCXR on admission, 14 patients developed DPX (2%) at 24-48 h later, and 52 patients presented up to 14 days later with DHX (7.4%). Of all DHX 42 (80.7%) required chest tube drainage, eight thoracentesis (16%) and only two (4%) were subjected after 1 month to decortication. No related morbidity was recorded. All the patients with the DHX had at least one rib fractured. Only one death among the DHX patients was documented.

CONCLUSIONS

A safe algorithm is recommended: eCXR for every patient who suffered blunt thoracic injury with at least one rib fracture detected and is treated as an outpatient or in case his/her compliance with the reevaluation schedule will be suboptimal. Close follow-up is also suggested since these entities do exist, cannot be ignored and their treatment is early evacuation of the pleura cavity.