Chest wall hematoma after central venous hemodialysis catheter insertion

Thoracodorsal Artery Injury After Tube Thoracostomy: A Case Report

BACKGROUND

Tube thoracostomy is rarely associated with serious bleeding complications. Although intercostal artery injury is a well-known bleeding complication, other vascular injuries in the chest wall have only rarely been reported.

CASE REPORT

A 58-year-old man with alcoholic liver cirrhosis presented to the emergency department with dyspnea. He was diagnosed by chest computed tomography with spontaneous hemopneumothorax, for which he underwent tube thoracostomy. However, bleeding in the chest wall continued, which required chest tube removal and blood transfusion. Contrast-enhanced computed tomography and angiography revealed contrast extravasation from the thoracodorsal artery, which confirmed a diagnosis of thoracodorsal artery injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because the thoracodorsal artery gives branches to the serratus anterior muscles that are located in the "triangle of safety," chest tube placement in this area is not always safe; it can still cause major bleeding complications from vessels such as the thoracodorsal artery. Hence, close monitoring for bleeding is needed after tube thoracostomy.

Non-traumatic ecchymoses: A literature review from a medico-legal perspective

Ecchymosis, as a general term, refers to discoloration of the skin due to the presence of extravasated blood into the dermis and/or subcutaneous tissue. However, it can occasionally be observed without any trauma, as a symptom of disease, a clinical condition, or even during the course of treating a disease. It is extremely important that these non-traumatic lesions are known and recognized and can be distinguished from traumatic ecchymoses by both clinicians and forensic scientists. This review of the literature includes detailed descriptions of non-traumatic periorbital ecchymosis, Slapped Cheek Syndrome, Cullen's Sign, Grey Turner's Sign, Stabler's Sign, Ransohoff Sign, Bryant's Sign, postsacral ecchymosis, perianal ecchymosis, Fox's Sign, other lower leg ecchymosis, and ecchymosis on various body regions. In this article, it is emphasized that failure to correctly identify these findings may subject practitioners to malpractice lawsuits, and failure to correctly identify findings by forensic experts may result in unjust legal judgments against people or loss of rights. It is also this review encourages accurate diagnosis of non-traumatic ecchymoses.

Massive hemothorax from injury of an anonymous vein after intercostal chest drain placement: A case report

Background

Placement of an intercostal chest drain (ICD) is an essential procedure in the management of patients with chest injuries. However, ICD placement can have complications. Here, we report a case of massive hemothorax due to injury of an anonymous vein associated with ICD placement.

Case presentation

An 84-year-old man with chronic right pleural effusion from pleuroperitoneal communication presented with dyspnea after a fall. An ICD was placed in the right seventh intercostal area on the middle axillary line. He later complained of chest pain and dyspnea again due to right pneumothorax, and massive hemorrhagic pleural effusion was drained from an additionally placed ICD. A contrast-enhanced computed tomography scan showed that bleeding from the parietal pleura traveled along the first ICD and dropped into the intrapleural space. Intraoperatively, there was intramuscular venule bleeding from the right serratus anterior muscle, which was then ligated to stop the bleeding.

Discussion

An optimal area to place an ICD is termed the "safety triangle", which is determined by the pectoralis major, latissimus dorsi, and the level of the nipples and the base of the axilla. In this case, the ICD was placed in the seventh intercostal area, which is more than two intercostal distances inferior to the 'safety triangle'.

Conclusions

This case suggested that, even though the vessel was small, a massive, life-threatening hemothorax can occur if an injury is caused by ICD placement. Knowledge of the anatomy necessary for placing an ICD should be reinforced.