Delayed massive hemothorax requiring surgery after blunt thoracic trauma over a 5-year period: complicating rib fracture with sharp edge associated with diaphragm injury

Delayed hemothorax following blunt thoracic trauma: a case report

BACKGROUND

Late hemothorax is a rare complication of blunt chest trauma. The longest reported time interval between the traumatic event and the development of hemothorax is 44 days.

CASE PRESENTATION

An elderly patient with right-sided rib fractures from chest trauma, managed initially with closed thoracostomy, presented with a delayed hemothorax that occurred 60 days after initial management, necessitating conservative and then surgical intervention due to the patient's frail condition and associated complications.

CONCLUSIONS

This case emphasizes the clinical challenge and significance of delayed hemothorax in chest trauma, highlighting the need for vigilance and potential surgical correction in complex presentations, especially in the elderly.

Delayed massive hemothorax after blunt thoracic trauma requiring thoracotomy by VATS: a case report

Delayed hemothorax after thoracic trauma is a rare type of thoracic injury that may require angioembolization and surgical treatment. We report a case of a 59-year-old man with a delayed massive hemothorax from a fall-induced blunt thoracic trauma, causing multiple right lower rib fractures. The patient fell from a chair while standing on and working from it. He was diagnosed with right 7th–11th rib fractures, scanty hemothorax and liver contusion. The patient was hospitalized and received conservative treatment, and a delayed massive hemothorax was present on the fourth day after the injury. Chest tube drainage and video-assisted thoracoscopic surgery were performed, and the patient was discharged 16 days after the surgery without bleeding or other complications. Delayed hemothorax should be considered when thoracic trauma patients complain of chest discomfort, dyspnea, cold sweating or fatigue. Early recognition, appropriate diagnosis and rapid intervention can improve prognosis and lead to successful patient treatment.

Delayed massive hemothorax due to diaphragm injury with rib fracture: A case report

•

Diaphragmatic injury can cause delayed hemothorax.

•

A thoracotomy should be considered in patients with delayed hemothorax and shock.

•

Delayed hemothorax required surgery to control bleeding from diaphragmatic injury.

Introduction

Delayed massive hemothorax after blunt trauma is rare, although associated with significant morbidity and mortality. In most cases, the intercostal artery is the main bleeding source. We report a rare case of delayed massive hemothorax due to a diaphragm injury with a lower rib fractures.

Presentation of case

A 58-year-old man, transported to our hospital four hours after a 2-meter fall from a ladder, had left-sided fractures to ribs 11 and 12, thoracic and lumbar vertebral fractures, and traumatic subarachnoid hemorrhage. On admission, no left hemothorax was documented; however, 17 h post-injury he developed hypovolemic shock. Plain chest radiographs showed a massive left hemothorax with a mediastinal shift. Chest contrast-enhanced computed tomography revealed extravasation of the contrast agent in the chest cavity. No intercostal arterial bleeding was evident on emergency angiography. A left anterolateral thoracotomy through the 6th intercostal space revealed rib fractures and active bleeding from the dorsal side of the left hemidiaphragm. Suture hemostasis was performed for the diaphragm injury and the disrupted ribs were repaired.

Discussion

Embolization of diaphragm-feeding arteries is not a simple or fast procedure. Clinically, predicting delayed hemothorax is challenging, and careful observation of trauma patients with lower rib fractures is needed. Thoracotomy should be considered for immediate hemostasis in patients with sudden shock, with complete hematoma drainage and repair of the disrupted rib.

Conclusion

Diaphragmatic injury with lower rib fractures can result in delayed hemothorax, requiring thoracotomy.

Real-Time Detection of Hemothorax and Monitoring its Progression in a Piglet Model by Electrical Impedance Tomography: A Feasibility Study

Hemothorax is a serious medical condition that can be life-threatening if left untreated. Early diagnosis and timely treatment are of great importance to produce favorable outcome. Although currently available diagnostic techniques, e.g., chest radiography, ultrasonography, and CT, can accurately detect hemothorax, delayed hemothorax cannot be identified early because these examinations are often performed on patients until noticeable symptoms manifest. Therefore, for early detection of delayed hemothorax, real-time monitoring by means of a portable and noninvasive imaging technique is needed. In this study, we employed electrical impedance tomography (EIT) to detect the onset of hemothorax in real time on eight piglet hemothorax models. The models were established by injection of 60 ml fresh autologous blood into the pleural cavity, and the subsequent development of hemothorax was monitored continuously. The results showed that EIT was able to sensitively detect hemothorax as small as 10 ml in volume, as well as its location. Also, the development of hemothorax over a range of 10 ml up to 60 ml was well monitored in real time, with a favorable linear relationship between the impedance change in EIT images and the volume of blood injected. These findings demonstrated that EIT has a unique potential for early diagnosis and continuous monitoring of hemothorax in clinical practice, providing medical staff valuable information for prompt identification and treatment of delayed hemothorax.

Delayed massive hemothorax due to a diaphragmatic laceration caused by lower rib fractures

A delayed hemothorax requiring surgical treatment is considered a rare minor thoracic injury. We experienced four cases of delayed massive hemothorax due to a diaphragmatic laceration caused by lower rib fractures. A computed tomography scan on admission revealed multiple rib fractures in all patients, and at least one fractured lower rib was severely displaced, which injured the diaphragm. The duration between the injury and the diagnosis were 14 h-30 days. Emergency surgical treatment was performed, and intraoperative findings revealed a diaphragmatic laceration with oozing due to injury caused by the edge of a fractured rib. After the operation, all patients were successfully discharged.

[Evaluation of the performance of a minimally invasive thoracic drainage tube in a rabbit model of hemothorax]

OBJECTIVE

To assess the performance of a minimally invasive thoracic drainage tube (14 F) made of polyurethane (PU) in a rabbit model of hemothorax in comparison with the conventional 28 F chest tube (CCT).

METHODS

Thirty New Zealand rabbits were divided into experimental chest tube (ECT) group (n=9), CCT group (n=6), and blood provider group (n=15). Blood samples (20 mL) collected from the blood providing rabbits were injected into the chest cavity of the rabbits in the other two groups, and the time taken for closed drainage of the thoracic cavity was recorded. The rabbits in ECT and CCT groups were subjected to blood injections (20 mL for each injection) into the chest cavity every 20 min for 5 times, and the volumes of blood drained by ECT and CCT were measured. Two hours later, the rabbits were sacrificed and the residual blood and blood clots in the chest cavities were observed.

RESULTS

Compared with CCT, the use of ECT significantly shortened the operation time (P < 0.05) and produced more effective blood drainage at 20 min and 40 min after the placement of the drainage tube (P < 0.05). No significant difference was found in the total blood volume drained between ECT and CCT groups, but the volume of residual blood in the thoracic cavity was significantly smaller in ECT group than in CCT group. No post-operative complications were found in the rabbits in ECT group while all the rabbits in CCT group had abutment pressure to the lung.

CONCLUSION

Compared to CCT, ECT is less invasive and allows more effective thoracic drainage with more convenient operation and reduced postoperative complications, suggesting its potential for use in closed thoracic drainage in single-port video-assisted thoracoscopic surgery (VATS) or in pediatric patients.