Hemothorax: A Review of the Literature

Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report

BACKGROUND

Intercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage.

CASE PRESENTATION

A 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful.

CONCLUSION

We report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

Small Hemothoraces Not Drained on Admission: Initial Volume Predicts Need for Intervention

BACKGROUND

Unlike large hemothoraces (HTX), small HTX after blunt trauma may be observed without drainage. We aimed to study if there were risk factors that would predict the need for intervention in initially observed small HTX.

METHODS

A retrospective review of patients with blunt traumatic HTX from 2016 to 2022 was performed. Patients with small HTX (pleural fluid volume <400 mL on admission chest computerized tomography [CT]) were included. Patients were considered as being "initially observed" if there was no intervention for the HTX within 48 hours after admission. Primary outcome was any HTX-related intervention (open, thoracoscopic or percutaneous procedures) occurring after 48 hours and up to 6 months after injury. Univariable and multivariable statistical analyses were employed. A P-value of <.05 was considered significant.

RESULTS

Of 335 patients with HTX, 188 (59.6%) met inclusion criteria. Median (interquartile range) HTX volume was 90 (36-134) ml. One hundred and twenty-seven (68%) were initially observed. Of these, 31 (24%) had the primary outcome. These patients had a larger HTX volume (median, 129 vs 68 mL, P = .0001), and number of rib fractures (median, 7 vs 4, P = .0002) compared to those without the primary outcome. Chest-related readmission occurred in 8 (6%) with a median of 20 days from injury. Of these, 7 required an HTX-related intervention. Logistic regression analysis found that both the number of rib fractures and HTX volume independently predicted the primary outcome.

CONCLUSION

For small HTX initially observed, number of rib fractures and initial volume predicted delayed HTX-related intervention.

Not So Vats: How Early Is Too Early in the Operative Management of Patients with Traumatic Hemothorax?

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is a practical resource in the management of traumatic hemothorax. However, it carries inherent risks and should be mobilized cost-effectively. In this study, we investigated the ideal VATS timing using cost analysis.

METHODS

617 cases of unilateral traumatic hemothorax from 2012 to 2022 were identified in our trauma database. We extracted encounter cost, length of stay (LOS), and operative cost information. Using Kruskal-Walli's test, we compared the cost and LOS for patients who underwent VATS or continued nonoperative management in the first 7 days of admission. Additionally, we computed the daily proportion of patients initially managed nonoperatively but ultimately underwent VATS. P-values <.05 were considered significant.

RESULTS

The median encounter cost of cases managed operatively before hospital day 4 (HD4) was higher than those managed nonoperatively. This difference was $63k on HD2 (P-value .07) and was statistically significant for HD3 (difference of $65k, P-value .02). The median LOS with operational management on HD2 and 3 was 7 and 6 respectively vs median LOS of 2 and 3 with nonoperative management on those days (P-value <.001, .01 respectively). The proportion of patients who failed nonoperative management did not change from baseline until HD4 (23% (95% CI 19.7, 26.3) vs 33.9% (95% CI 28.3, 39.6), P-value <.001).

DISCUSSION

Early mobilization of VATS before hospital day 4 increases the overall hospital cost without offering any length of stay benefit. Continuing nonoperative management longer than 4 days is associated with a high failure rate and a costlier operation.

The Role of Minimally Invasive Surgeries in Trauma

This article delves into the role of minimally invasive surgeries in trauma, specifically laparoscopy and video-assisted thoracic surgery (VATS). It discusses the benefits of laparoscopy over traditional laparotomy, including its accuracy in detecting peritoneal violation and intraperitoneal injuries caused by penetrating trauma. The article also explores the use of laparoscopy as an adjunct to nonoperative management of abdominal injuries and in cases of blunt trauma with unclear abdominal injuries. Furthermore, it highlights the benefits of VATS in diagnosing and treating thoracic injuries, such as traumatic diaphragmatic injuries, retained hematomas, and persistent pneumothorax.

Beyond diagnosis: a narrative review of the evolving therapeutic role of medical thoracoscopy in the management of pleural diseases

Background and Objective

Medical thoracoscopy (MT) is an endoscopic technique performed by interventional pulmonologists with a favorable safety profile and few contraindications, providing diagnostic and therapeutic intervention in a single sitting. This narrative review was designed to summarize the therapeutic role of MT based on the latest results from the available literature.

Methods

Pertinent literature published in English, relative to human studies, between 2010-2022 was searched in Medline/PubMed and Cochrane databases. Publications regarded as relevant were considered for inclusion in this review; additional references were added based on the authors' knowledge and judgment. The review considered population studies, meta-analyses, case series, and case reports.

Key Content and Findings

MT has mostly been described and is currently used globally in the diagnostic approach to exudative pleural effusion of undetermined origin. Carefully evaluating the literature, it is clear that there is initial evidence to support the use of MT in the therapeutic approach of malignant pleural effusion, pneumothorax, empyema, and less frequently hemothorax and foreign body retrieval.

Conclusions

MT is an effective procedure for treating the clinical entities presented in this document; it must be carried out in selected patients, managed in centers with high procedural expertise. Further evidence is needed to assess the optimal indications and appropriate patients' profiles for therapeutic MT. The endpoints of length of hospital stay, surgical referral, complications and mortality will have to be considered in future studies to validate it as a therapeutic intervention to be applied globally.

Risk factors for delayed hemothorax in patients with rib fracture in the emergency department

OBJECTIVES

Although rib fractures are a risk factor, not all rib fracture patients will develop delayed hemothorax. This study aimed to evaluate risk factors which can identify rib fracture patients in the emergency department who may develop delayed hemothorax.

METHODS

Adult patients seen in the emergency room between January 2016 and February 2021 with rib fractures caused by blunt chest trauma were included in this retrospective observational study. Patients who underwent chest tube insertion within 2 days and those without follow-up chest radiographs within 2-30 days were excluded. We used a stepwise backward-elimination multivariable logistic regression model for analysis.

RESULTS

A total of 202 patients were included in this study. The number of total (P < 0.001), lateral (P = 0.019), and displaced (P < 0.001) rib fractures were significantly associated with delayed hemothorax. Lung contusions (P = 0.002), and initial minimal hemothorax (P < 0.001) and pneumothorax (P < 0.001) were more frequently associated with delayed hemothorax. Age (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.00-1.06, P = 0.022), mechanical ventilator use (aOR 9.67, 95% CI 1.01-92.75, P = 0.049), initial hemothorax (aOR 2.21, 95% CI 1.05-4.65, P = 0.037) and pneumothorax (aOR 2.99, 95% CI 1.36-6.54, P = 0.006), and displaced rib fractures (aOR 3.51, 95% CI 1.64-7.53, P = 0.001) were independently associated with delayed hemothorax.

CONCLUSIONS

Age, mechanical ventilation, initial hemo- or pneumothorax, and displaced rib fractures were risk factors for delayed hemothorax. Patients with these risk factors, and especially those with ≥2 displaced rib fractures, require close chest radiography follow-up of 2-30 days after the initial trauma.

A Novel Rabbit Model of Retained Hemothorax with Pleural Organization

Retained hemothorax (RH) is a commonly encountered and potentially severe complication of intrapleural bleeding that can organize with lung restriction. Early surgical intervention and intrapleural fibrinolytic therapy have been advocated. However, the lack of a reliable, cost-effective model amenable to interventional testing has hampered our understanding of the role of pharmacological interventions in RH management. Here, we report the development of a new RH model in rabbits. RH was induced by sequential administration of up to three doses of recalcified citrated homologous rabbit donor blood plus thrombin via a chest tube. RH at 4, 7, and 10 days post-induction (RH4, RH7, and RH10, respectively) was characterized by clot retention, intrapleural organization, and increased pleural rind, similar to that of clinical RH. Clinical imaging techniques such as ultrasonography and computed tomography (CT) revealed the dynamic formation and resorption of intrapleural clots over time and the resulting lung restriction. RH7 and RH10 were evaluated in young (3 mo) animals of both sexes. The RH7 recapitulated the most clinically relevant RH attributes; therefore, we used this model further to evaluate the effect of age on RH development. Sanguineous pleural fluids (PFs) in the model were generally small and variably detected among different models. The rabbit model PFs exhibited a proinflammatory response reminiscent of human hemothorax PFs. Overall, RH7 results in the consistent formation of durable intrapleural clots, pleural adhesions, pleural thickening, and lung restriction. Protracted chest tube placement over 7 d was achieved, enabling direct intrapleural access for sampling and treatment. The model, particularly RH7, is amenable to testing new intrapleural pharmacologic interventions, including iterations of currently used empirically dosed agents or new candidates designed to safely and more effectively clear RH.

From diagnosis to therapy: the acute traumatic hemothorax - an orientation for young surgeons

Introduction

This review aims to provide an overview of diagnosing and managing traumatic haemothorax for young surgeons.

Content

Of 27,333 polytrauma patients in Germany in 2021, 35 % were admitted with thoracic trauma. In polytrauma patients, chest injuries are an independent negative predictor of 30-day mortality. These patients should be treated in an evidence-based and standardized manner to reduce mortality and morbidity. There are several methods of immediate diagnosis that should be used depending on hemodynamic stability. In addition to physical examination and chest X-ray, more specific techniques such as the eFAST protocol and Computed tomography (CT) of the chest  are available. Once the source of bleeding has been identified, acute treatment is given depending on hemodynamic stability. Thoracic drainage remains the gold standard in the initial management of hemothorax. If surgery is required because of an active source of bleeding, a hemothorax that has not been completely relieved, or associated injuries, either a minimally invasive or open approach can be used. The main focus is to stabilize the patient and avoid early and late complications.

Summary and Outlook

Rapid and prompt diagnosis and management of traumatic hemothorax is essential for patient outcome and should be taught to all young surgeons who are in direct contact with these patients.

Delayed hemothorax readmissions after rib fracture in blunt trauma patients

Background

Rib fractures are the most common traumatic injury. Hemothorax is one of the widespread complications associated with a rib fracture and occurs in 10-37 % of all rib fractures. Delayed hemothorax (DHTX) is defined as an accumulation of blood within the pleural cavity. Although there is extensive literature on hemothorax, there is limited literature on rib fractures and DHTX readmissions. The objective of this study was to identify potential risk factors for DHTX readmission and examine descriptive information on readmission.

Methods

Using the 2016-2019 National Readmission Database (NRD), patients that experienced an admission with a blunt traumatic rib fracture were included. It was determined if the patients experienced DHTX by screening for an admission containing an ICD-10 code for hemothorax within 30 days after an admission containing a ICD-10 code for rib fracture. Univariable and multivariable analysis was performed to determine independent risk factors associated with DHTX readmission. Additionally, information on the clinical and financial characteristics of DHTX readmissions were examined.

Results

A total of 242,071 patients were included, of whom 635 experienced DHTX readmission ≤30 days after discharge. Diagnosed with hemothorax on the index admission had the largest odds ratio for DHTX readmission (7.43 [6.14-8.99], P < 0.001). Complications found during DHTX readmission included acute respiratory failure (16.9 %), sepsis (6.9 %), and empyema (4.3 %). Treatment mainly consisted of pleural drainage (62.2 %) and video-assisted thoracoscopic surgery (VATS) evacuation of hemothorax (10.1 %).

Conclusion

Patients admitted for a rib fracture have a low incidence for DHTX readmission within 30 days. However, multivariable analysis has demonstrated some risk and protective factors associated with DHTX readmission. Further studies should focus on exploring these risk factors to screen for potential DHTX readmission and/or protective factors to decrease the change for DHTX readmission.

Does preinjury anticoagulation worsen outcomes among traumatic hemothorax patients? A nationwide retrospective analysis

INTRODUCTION

Up to a quarter of all traumatic deaths are due to thoracic injuries. Current guidelines recommend consideration of evacuation of all hemothoraces with tube thoracostomy. The aim of our study was to determine the impact of pre-injury anticoagulation on outcomes of traumatic hemothorax patients.

MATERIALS AND METHODS

We performed a 4-year (2017 - 2020) analysis of the ACS-TQIP database. We included all adult trauma patients (age ≥18 years) presenting with hemothorax and no other severe injuries (other body regions <3). Patients with a history of bleeding disorders, chronic liver disease, or cancer were excluded from this study. Patients were stratified into two groups based on the history of preinjury anticoagulant use (AC, preinjury anticoagulant use: No-AC, no preinjury anticoagulant use). Propensity score matching (1:1) was done by adjusting for demographics, ED vitals, injury parameters, comorbidities, thromboprophylaxis type, and trauma center verification level. Outcome measures were interventions for hemothorax (chest tube, video-assisted thoracoscopic surgery [VATS]), reinterventions (chest tube > once), overall complications, hospital length of stay (LOS), and mortality.

RESULTS

A matched cohort of 6,962 patients (AC, 3,481; No-AC, 3,481) was analyzed. The median age was 75 years, and the median ISS was 10. The AC and No-AC groups were similar in terms of baseline characteristics. Compared to the No-AC group, AC group had higher rates of chest tube placement (46% vs 43%, p = 0.018), overall complications (8% vs 7%, p = 0.046), and longer hospital LOS (7[4-12] vs 6[3-10] days, p ≤ 0.001). Reintervention and mortality rates were similar between the groups (p>0.05).

CONCLUSION

The use of preinjury anticoagulants in hemothorax patients negatively impacts patient outcomes. Increased surveillance is required while dealing with hemothorax patients on pre-injury anticoagulants, and consideration should be given to earlier interventions for such patients.

Hemothorax after sneezing

Acute hemothorax is generally known to be a sequela of trauma to the chest, rupture of aortic aneurysm, or aortic dissection. Other causes of hemothorax have been attributed to iatrogenic, vascular, neoplastic, coagulopathy, or infectious processes. Although there has been a single report of spontaneous rupture of intercostal artery after coughing, there have been no reports of the same from sneezing. This rare presentation highlights the importance of a full evaluation for patients who present with viral symptoms such as sneezing or coughing along with a complaint of chest pain because massive hemothorax can be life-threatening.

Case report: Spontaneous hemothorax following anticoagulation for microthrombi in severe COVID pneumonia

Background

Anticoagulant therapy has become a hallmark of treatment for critically ill COVID patients. Gastrointestinal and intracranial hemorrhage are known major complications of anticoagulation, but spontaneous hemothorax is a rare event, particularly in the absence of pre-existing structural lung disease, vascular malformations, or genetic bleeding diatheses. Herein is a case of spontaneous hemothorax following anticoagulation for microthrombi in a patient with acute hypoxic respiratory failure due to Covid pneumonia.

Case presentation

A 49 year old male with hypertension, asthma, and obesity was admitted for acute hypoxic respiratory failure due to Covid pneumonia. He was treated with dexamethasone, baricitinib, and therapeutic enoxaparin as empiric therapy for severe COVID disease. He subsequently developed a massive right hemothorax with associated hemorrhagic shock, which required initiation of massive transfusion protocol, vasopressor support and mechanical ventilation. No clear etiology for the hemothorax was determined upon investigations. The patient eventually improved and was discharged to a skilled nursing facility on chronic oxygen therapy.

Conclusions

Various mechanisms have been proposed for the development of non-traumatic hemothoraces, including tearing of adhesions and rupture of vascularized bullae. Such explanations find support in radiologic and pathologic studies of pleural changes in Covid pneumonia, and likely played a role in the hemorrhage experienced by our patient.

Video assisted thoracoscopic surgery vs thoracotomy in management of post traumatic retained hemothorax: a randomized study

Background

Retained hemothorax is a serious problem that can lead to empyema or fibro-thorax. Evacuation of the retained hemothorax is commonly performed via open thoracotomy. This randomized study was conducted to represent our center's expertise with this issue, we compared the outcomes of video-assisted thoracoscopic surgery (VATS) against open thoracotomy in managing post-traumatic retained clotted hemothorax.

Methods

This prospective randomized research was conducted on sixty cases with posttraumatic remaining clots of at least 500 ml or at least one-third of haemothorax that cannot be evacuated by a chest tube after 72 h of first intervention, as detected by computed tomography imaging who underwent open thoracotomy or VATS in the management of posttraumatic retained clotted hemothorax. Cases were allocated to equal groups; group A: cases who underwent VATS and group B: cases who underwent open thoracotomy.

Results

Preoperative intercostal chest tube (ICT) placement period was insignificantly different between the two groups. Group A had a significantly lesser post-operative amount of ICT drainage, and ICT was removed after significantly fewer days than in group B (P value < 0.001). Post-operatively, the numerical rating scale (NRS) was significantly higher at post-extubation and 6 h after extubation in group B than group A (P value < 0.05) and was insignificantly different between both groups the next morning, after chest tube removal and before discharge. group A had statistically better NRS versus group B (P value < 0.001). Wound infection incidence was significantly less in group A compared to group B (P value = 0.025); the incidence of air leak was insignificantly different between both groups. Group A has significantly shorter hospitalization than group B (P value < 0.001). Wound infection and empyema in outcases were insignificantly different between both groups (P value = 0.492). Cases in group A returned to normal activity earlier than group B (P value < 0.001).

Conclusions

VATS in managing posttraumatic retained hemothorax was a more effective, well-tolerated, and reliable intervention that can be easily utilized for managing posttraumatic retained hemothorax in comparison to open thoracotomy.

[Occult and Retained Haemothorax - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Trauma Society (DGU - Section NIS) and the German Society for Thoracic Surgery (DGT)]

The management of occult and retained haemothorax is challenging for all involved in the care of polytrauma patients in terms of diagnosis and treatment. The focus of decision making is preventing sequelae such as pleural empyema and avoiding a trapped lung. An interdisciplinary task force of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU) on thoracic trauma offers recommendations for post-trauma care of patients with occult and/or retained haemothorax, as based on a comprehensive literature review.

Efficacy of extended focused assessment with sonography for trauma using a portable handheld device for detecting hemothorax in a low resource setting; a multicenter longitudinal study

Introduction

Chest trauma is one of the most important and commonest injuries that require timely diagnosis, accounting for 25–50% of trauma related deaths globally. Although CT scan is the gold standard for detection of haemothorax, it is only useful in stable patients, and remains unavailable in most hospitals in low income countries. Where available, it is very expensive. Sonography has been reported to have high accuracy and sensitivity in trauma diagnosis but is rarely used in trauma patients in low income settings in part due to lack of the sonography machines and lack of expertise among trauma care providers. Chest X-ray is the most available investigation for chest injuries in low income countries. However it is not often safe to wheel seriously injured, unstable trauma patients to X-ray rooms. This study aimed at determining the efficacy of extended focused assessment with sonography for trauma (eFAST) in detection of haemothorax using thoracostomy findings as surrogate gold standard in a low resource setting.

Methods

This was an observational longitudinal study that enrolled 104 study participants with chest trauma. Informed consent was obtained from all participants. A questionnaire was administered and eFAST, chest X-ray and tube thoracotomy were done as indicated. Data were analysed using SPSS version 22. The sensitivity, specificity, predictive values, accuracy and area under the curve were determined using thoracostomy findings as the gold standard. Ethical approval for the study was obtained from the Research and Ethics Committee of Kampala International University Western Campus REC number KIU-2021-53.

Results

eFAST was found to be superior to chest X-ray with sensitivity of 96.1% versus 45.1% respectively. The accuracy was also higher for eFAST (96.4% versus 49.1%) but the specificity was the same at 100.0%. The area under the curve was higher for eFAST (0.980, P = 0.001 versus 0.725, P = 0.136). Combining eFAST and X-ray increased both sensitivity and accuracy.

Conclusion

This study revealed that eFAST was more sensitive at detecting haemothorax among chest trauma patients compared to chest X-ray. All patients presenting with chest trauma should have bedside eFAST for diagnosis of haemothorax.

The cost of treatments for retained traumatic hemothorax: A decision analysis

INTRODUCTION

Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies.

METHODS

A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy.

RESULTS

In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was >83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was <$33,900.

CONCLUSION

Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.

Chest Trauma Management in Low- and Middle-Income Countries

Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.

Spontaneous Haemothorax in a Patient with COVID-19

The global pandemic of COVID-19 is caused by SARS-CoV-2 virus. We continue to discover the wide spectrum of complications associated with COVID-19. Some well-known complications include pneumonia, acute respiratory distress syndrome, pneumothorax, disseminated intravascular coagulation (DIC), chronic fatigue, multiorgan dysfunction, and long COVID-19 syndrome. We report a rare case of a 51-year-old man with severe COVID-19 pneumonia who developed haemorrhagic shock secondary to spontaneous haemothorax after 17 days of hospitalisation. Clinicians should be aware of such occurrence, and hence, high clinical suspicion, prompt recognition of signs and symptoms of shock, and adequate resuscitation will improve the outcomes of patients.

Gunshot injury to the chest wall with an unusual bullet trajectory: A rare case report

INTRODUCTION AND IMPORTANCE

Gunshot injuries are always a challenging case for a surgeon. Early assessment of trajectory of bullet leads to effective surgical plan. These cases require multidisciplinary approach for the satisfactory outcome.

CASE PRESENTATION

We present a case of 38-year-old male with gunshot injury over left anterior chest wall with an entry wound and no detectable exit wound. Contrast enhanced computed tomogram (CECT) thorax and abdomen was suggestive of an unusual route of a bullet from left anterior chest wall at the level of 5th costochondral junction to the right iliac fossa region. Emergency exploration for the bullet was performed based on CECT findings which confirmed bullet in subcutaneous plane in right iliac fossa. Patient was discharged on 3rd post-operative with satisfactory clinical improvement.

CLINICAL DISCUSSION

Unusual presentations of bullet trajectory in gunshot injury can create surgical and/or medico-legal diagnostic problems. An effective surgical plan requires an effective clinic-radiological assessment. Accurate detection of entry wound, exit wound, path and extent of tissue damage is significant in preoperative planning and prognosis of patient. However not every patient with gunshot injury has an unusual trajectory. But accurate radiological assessment in such challenging cases is a necessity. Multidisciplinary approach with preoperative planning is required for satisfactory outcome.

CONCLUSION

Management of patients of gunshot injury is challenging for the attending surgeon. Multidisciplinary approach for preoperative planning along with good post-operative care is required in such cases of gunshot injury with atypical course.

It is Time to Replace Large Drains with Small Ones After Fixation of Rib Fractures: A Prospective Observational Study

Introduction

Large-bore chest tubes are usually applied after thoracic surgery. Recently, small-bore tubes have been increasingly considered owing to the extensive use of video-assisted thoracoscopic surgery (VATS). This study assessed the differences in outcomes between large-bore and small-caliber drainage tubes in patients undergoing surgical stabilization of rib fractures (SSRF) with VATS.

Methods

Overall, 131 patients undergoing SSRF with VATS were prospectively enrolled, including 65 patients receiving 32-Fr chest tubes (group 1) and 66 patients receiving 14-Fr pigtail catheters (group 2) for postoperative drainage. The clinical characteristics and perioperative outcomes of the patients were compared.

Results

All patients underwent SSRF with VATS within 4 days after trauma. After the operation, the mean duration of chest tubes was longer than that of pigtail catheters, with statistical significance (5.08 ± 2.47 vs 3.11 ± 1.31, P = 0.001). Length of stay (LOS) was also longer in group 1 (10.38 ± 2.90 vs 8.18 ± 2.44, P = 0.001). After multivariate logistic regression, the only independent factors between the two groups were duration of postoperative drainage (adjusted odds ratio [AOR] 1.746; 95% confidence interval [CI] 0.171–10.583, P = 0.001) and hospital LOS (AOR 1.272; 95% CI 0.109–4.888, P = 0.027).

Conclusion

After reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS.

Role of Interventional Radiology in the Management of Non-aortic Thoracic Trauma

Trauma remains a leading cause of death for all age groups, and nearly two-thirds of these individuals suffer thoracic trauma. Due to the various types of injuries, including vascular and nonvascular, interventional radiology plays a major role in the acute and chronic management of the thoracic trauma patient. Interventional radiologists are critical members in the multidisciplinary team focusing on treatment of the patient with thoracic injury. Through case presentations, this article will review the role of interventional radiology in the management of trauma patients suffering thoracic injuries.

The Role of Surgery in Patients with COVID-19-Related Thoracic Complications

Objective

Patients with several thoracic complications induced by SARS-CoV-2 infection may benefit from surgery, but its role in this condition is largely unknown, and many surgeons’ advice against any surgical referrals. Our aim is to investigate the efficacy and safety of surgery in COVID-19 patients with thoracic complications requiring surgery.

Methods

We designed a multicenter observational study, involving nine thoracic surgery departments, evaluating patients who developed thoracic complications in hospital, surgically managed from March 1, 2020, to May 31, 2021. An overall 30-day mortality was obtained by using the Kaplan–Meier method. Multivariable Cox regression model and logistic models were applied to identify the variables associated with mortality and postoperative complications.

Results

Among 83 patients, 33 (40%) underwent surgery for complicated pneumothorax, 17 (20.5%) for pleural empyema, 13 (15.5%) for hemothorax, 8 (9.5%) for hemoptysis, 5 patients (6%) for lung abscess, 4 (5%) for infected pneumatoceles, and 3 (3.5%) for other causes. Within 30 days of surgery, 60 patients (72%) survived. At multivariable analysis, age (HR 1.05 [95% CI, 1.01, 1.09], p = 0.022), pulmonary hypertension (HR 3.98 [95% CI, 1.09, 14.5], p = 0.036), renal failure (HR 2.91 [95% CI, 1.19, 7.10], p-value 0.019), thoracotomy (HR 4.90 [95% CI, 1.84, 13.1], p-value 0.001) and infective affections (HR 0.17 [95% CI, 0.05, 0.58], p-value 0.004) were found to be independent prognostic risk factors for 30-day mortality. Age (OR 1.05 [95% CI, 1.01, 1.10], p = 0.023) and thoracotomy (OR 3.85 [95% CI, 1.35, 12.0] p = 0.014) became significant predictors for 30-day morbidity.

Conclusion

Surgical management of COVID-19-related thoracic complications is affected by high mortality and morbidity rates, but a 72% survival rate still seems to be satisfactory with a rescue intent. Younger patients without pulmonary hypertension, without renal insufficiency and undergoing surgery for infectious complications appear to have a better prognosis.

A Case of Bilateral Hemorrhagic Pleural Effusion Due to Dual Antiplatelet Therapy in a Dialysis Patient

Etiologies of hemorrhagic pleural effusions (hemithoraces) are multifactorial. They can be traumatic, non-traumatic, or idiopathic in nature. In this report, we present a rare case of a 64-year-old male with end-stage renal disease (ESRD) on chronic hemodialysis and dual antiplatelet therapy (DAPT), due to a recent history of coronary arterial stent placement, who presented with progressive shortness of breath for one month. The CT of the chest revealed bilateral large pleural effusions (left > right) with a complete collapse of the left lung and partial collapse of the right lung. Ultrasound-guided left-sided thoracentesis revealed hemorrhagic pleural effusions. After the discontinuation of DAPT, drainage from the right-sided pleural effusion via a pigtail catheter showed continued drainage of pleural fluid without hemorrhage. The effusion on the left side was also noted to have resolved on the repeat chest X-ray. Prompt recognition of this rare cause of any hemorrhagic pleural effusion is essential for patients on dialysis to avoid complications. This report focuses on the possible etiology and potential complications of a hemorrhagic pleural effusion, followed by a brief discussion on the rare but significant association involving the incidence of a hemorrhagic pleural effusion in a dialysis patient receiving DAPT.

Pulmonary Artery Bleed from an Eloesser flap

An open thoracic window involves the creation of a semi-permanent pleural-cutaneous connection to treat chronic organising empyemas, bronchopleural fistulas and postpneumonectomy empyemas in patients too ill for video-assisted thoracic surgery decortication. An Eloesser flap is a type of open thoracic window. Antibiotics have made the use of Eloesser flaps and other open thoracic windows for treatment of empyemas rare. Consequently, not much is known about the chronic complications of open thoracic windows. However, structural compromise of vasculature secondary to chronic inflammation has been previously proposed as a mechanism for spontaneous pulmonary haematomas related to anatomic deformation. We depict a case of spontaneous pulmonary arterial bleed presenting as chest wall haemorrhage due to a chronic modified Eloesser flap.

Case Report: Penetrating Thoracic Trauma by A Gunshot Involving the Heart

Firearm-related mortality is not frequently encountered in a country like Nepal where there are stringent laws prohibiting the buying, selling, carrying or storing of firearms. To possess a firearm a person must have a valid license. Wounds produced by firearms have typical characteristics the knowledge of which helps to identify the type of firearm used, range of fire, the position of the victim, and whether the manner of death was homicidal, suicidal, or accidental. The present case is the first autopsy-based study from Nepal which discusses the wounds produced by firearms with an interpretation of such findings for medicolegal purposes. The present case highlights a social problem where the victim, a psychiatric patient, had no access to prescription medication due to coronavirus disease (COVID-19) related lockdown.

Imaging Manifestations of Chest Trauma

Trauma is the leading cause of death among individuals under 40 years of age, and pulmonary trauma is common in high-impact injuries. Unlike most other organs, the lung is elastic and distensible, with a physiologic capacity to withstand significant changes in contour and volume. The most common types of lung parenchymal injury are contusions, lacerations, and hematomas, each having characteristic imaging appearances. A less common type of lung injury is herniation. Chest radiography is often the first-line imaging modality performed in the assessment of the acutely injured patient, although there are inherent limitations in the use of this modality in trauma. CT images are more accurate for the assessment of the nature and extent of pulmonary injury than the single-view anteroposterior chest radiograph that is typically obtained in the trauma bay. However, the primary limitations of CT concern the need to transport the patient to the CT scanner and a longer processing time. The American Association for the Surgery of Trauma has established the most widely used grading scale to describe lung injury, which serves to communicate severity, guide management, and provide useful prognostic factors in a systematic fashion. The authors provide an in-depth exploration of the most common types of pulmonary parenchymal, pleural, and airway injuries. Injury grading, patient management, and potential complications of pulmonary injury are also discussed. ^©RSNA, 2021.