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Nyatsambo C, Moeng MS, Ngwisanyi W. A case report on chylothorax post penetrating chest trauma. Int J Surg Case Rep 2023; 110:108637. [PMID: 37572469 PMCID: PMC10428025 DOI: 10.1016/j.ijscr.2023.108637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Chylothorax is a rare condition secondary to a chyle leak from the thoracic duct. The most common cause is after thoracic and cardiac surgery. Other causes include malignancy, non-iatrogenic trauma, and miscellaneous disorder - tuberculosis, filariasis and idiopathic conditions. The incidence of chylothorax post non-iatrogenic trauma is low; however, it does occur. Therefore, clinicians managing trauma patients should be aware of chylothorax as a differential and understand how it can be managed. PRESENTATION OF CASE Our patient presented in respiratory distress 5 days after sustaining a stab to the chest. His chest X-ray showed a massive left pleural effusion with mediastinal shift. An Intercostal drain (ICD) was inserted and, drained 2 l of a white milky fluid - confirmed to be chyle on biochemistry. Other potential differentials like empyema and a pseudochylothorax, were excluded. He was kept nil-per os, received total parenteral nutrition and the ICD output was monitored. Subsequently the drainage decreased and eventually cleared, and the ICD was removed on day 8 of admission. Chest X-rays showed resolution of the effusion, and the patient was discharged. DISCUSSION Patients with trauma can present with chylothorax after penetrating or blunt trauma. The diagnosis can be made by checking the fluid triglyceride level or the presence of chylomicrons. Once the diagnosis is confirmed, the clinician should decide on either conservative or surgical. Due to the condition's rarity, there are no randomized control trials comparing different treatment modalities. CONCLUSION Despite the patient's delayed presentation, he was successfully managed conservatively.
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Affiliation(s)
- Chido Nyatsambo
- Division of Acute Care Surgery, Department of Surgery, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Soweto, South Africa.
| | - Maeyane Steve Moeng
- Division of Trauma, Department of General Surgery, Charlotte Maxeke Johannesburg Academic Hospital, 5 Jubilee Street, Parktown, Johannesburg, South Africa
| | - Weludo Ngwisanyi
- Division of General Surgery, Department of General Surgery, Charlotte Maxeke Johannesburg Academic Hospital, 5 Jubilee Street, Parktown, Johannesburg, South Africa
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Zhao W, Chu M, Ma L, Minervini F, Molnar TF, Zheng E, Ni J, Yang M, Zhao G. Penetrating chest trauma caused by a falling metallic bar: a case report. J Thorac Dis 2023; 15:4027-4032. [PMID: 37559653 PMCID: PMC10407516 DOI: 10.21037/jtd-23-767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/08/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Impaling injuries to the chest are relatively rare and often lethal. Initial evaluation, resuscitation, and surgical planning can be challenging for emergency physicians and surgeons. Chest trauma can be classified as either closed or penetrating, depending on whether or not the pleural cavity is open. Penetrating objects entering chest cavity frequently make an entrance and exit and are often accompanied by visceral/vascular damage. Open thoracotomy or video-assisted thoracic surgery (VATS) are considered the first-line approaches for severe penetrating chest trauma. CASE DESCRIPTION A 63-year-old male patient sustained a penetrating chest trauma caused by a T-shaped metallic bar falling from a height of 16 meters above the ground. After laboratory and imaging tests, as well as pre-operative preparation, the object was pulled out from the entry site after disinfection with surgical standby. Closed chest tube drainage was promptly performed, with chest tubes inserted through the entry and exit sites. The patient was discharged on postoperative day 14 in a good condition. Regular telephone follow-ups over 3 years showed that the patient recovered well after discharge. CONCLUSIONS For penetrating non-cardiac chest trauma patients in stable condition, it is necessary to complete an exhaustive imaging evaluation to determine the specific position of the foreign body and identify any injuries to major vessels and organs. If the condition permits, direct removal of foreign bodies is allowed, ideally under VATS control. Surgeons should evaluate the best option for each case based on the available resources.
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Affiliation(s)
- Weidi Zhao
- Department of Cardiothoracic Surgery, Ningbo No. 2 Hospital, Ningbo, China
- Health Science Center, Ningbo University, Ningbo, China
| | - Minghui Chu
- Department of Cardiothoracic Surgery, Ningbo No. 2 Hospital, Ningbo, China
- Health Science Center, Ningbo University, Ningbo, China
| | - Lingzhen Ma
- Department of Cardiothoracic Surgery, Ningbo No. 2 Hospital, Ningbo, China
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Tamas F. Molnar
- Department of Operational Medicine, Faculty of Medicine, University of Pécs, Pécs, Hungary
| | - Enkuo Zheng
- Department of Cardiothoracic Surgery, Ningbo No. 2 Hospital, Ningbo, China
| | - Junjun Ni
- Department of Cardiothoracic Surgery, Ningbo No. 2 Hospital, Ningbo, China
| | - Minglei Yang
- Department of Cardiothoracic Surgery, Ningbo No. 2 Hospital, Ningbo, China
| | - Guofang Zhao
- Department of Cardiothoracic Surgery, Ningbo No. 2 Hospital, Ningbo, China
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Sah B, Pant A, Jaiswal LS, Gupta RK. Penetrating Chest trauma with right atrium rupture - A case report. Trauma Case Rep 2023; 43:100758. [PMID: 36660403 PMCID: PMC9843243 DOI: 10.1016/j.tcr.2023.100758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 01/09/2023] Open
Abstract
Background Penetrating chest trauma can have lethal consequences. Anterior chest wall penetrating injury can cause fatal lacerations over the chest wall, lungs, pericardium, and the heart. There are few reports on these kinds of injuries and operative management. Purpose To describe a case of penetrating chest trauma with right atrium ruptured, after a fall from height. The patient was successfully managed with prompt resuscitation and definitive surgical intervention. Case presentation A 48-years-old gentleman presented with history of fall from height and right sided penetrating chest injury. The patient had a penetrating injury to the right-fourth intercostal space in parasternal region. Chest X-ray showed massive right-sided hemothorax and chest tube drained more than 1700 ml upon insertion. Emergency right thoracotomy was performed, after initial resuscitation with fluids and blood transfusion in the emergency department. He had injury to the intercostal arteries, lacerations of the pericardium and the right atrium ruptured, which was managed successfully with definitive repair. Conclusion Survival is rare after penetrating chest trauma with right atrium ruptured if not intervened on time. Prompt diagnosis and resuscitation, along with the definitive surgical repair were the key elements for successful management of the patients.
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Nyilas S, Ott D, von Tengg-Kobligk H, Poellinger A, Dorn P. Penetrating chest trauma after attempted suicide: An extraordinary behavior of a posttraumatic pulmonary artery pseudoaneurysm. J Radiol Case Rep 2020; 14:19-25. [PMID: 33088416 DOI: 10.3941/jrcr.v14i7.3842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Posttraumatic pulmonary artery pseudoaneurysm is a very rare, yet potentially lethal complication after thoracic trauma. Pulmonary artery pseudoaneurysm is associated with high mortality. Still literature highlights that untreated, lesions can enlarge, rupture, and lead to exsanguination and death. We present a case of a posttraumatic peripheral pulmonary artery pseudoaneurysm with complete disappearance after one year. This case confirms that conservative treatment can be an effective option in asymptomatic and stable patients.
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Affiliation(s)
- Sylvia Nyilas
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Daniel Ott
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hendrik von Tengg-Kobligk
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Alexander Poellinger
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Patrick Dorn
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Augustin P, Guivarch E, Tran-Dinh A, Pellenc Q, Tanaka S, Montravers P. Usefulness of CT-scan in the management of chest stab trauma: a prospective observational study. Eur J Trauma Emerg Surg 2020; 46:1385-91. [PMID: 31407022 DOI: 10.1007/s00068-019-01203-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/05/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE The management of chest stab wounds necessitates to perform an efficient imaging strategy. Compared to chest X-ray, computed tomography (CT) scan has a higher sensitivity. Nevertheless, the utility of diagnosing occult injuries remains controversial. Previous studies reported very different rates of management modifications induced by CT-scan. Indeed, no study specifically addressed the issue of ruling out traumatic diaphragmatic injury (TDI) in the specific population of chest stab trauma. The aim of the study was to evaluate the rate of thoracic procedures induced or guided by the results of thoracic CT-scan in the specific population of chest stab wounds. Secondary objective was to evaluate the utility of CT-scan for the diagnosis of TDI. METHODS We conducted a prospective observational study. All consecutive patients referred to the acute care unit were included. We recorded the general characteristics of patients, the localization of wounds, all imaging tests, the final injury diagnosis, and the patients' management. We compared patients with modifications of management induced by CT-scan results to other patients. We evaluated the performance of CT-scan for the diagnosis of TDI by calculating its sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). RESULTS 153 patients were included. There were 92 patients with normal chest X-ray. 67 of them received a CT-scan. 34 (51%) patients had an abnormal CT-scan, including 19 (21%) patients with thoracic new findings, with 3 (4.5%) modification of management. There were 50 patients who had an abnormal chest X-ray. 31 of them received a CT-scan, and 31 (100%) had an abnormal CT-scan, including 19 thoracic new findings, with 11 (36%) modifications of management. The diagnostic performance of CT-scan for TDI was: sensitivity 50%; specificity 95%; NPV 72%; PPV 88%. CONCLUSIONS In chest stab trauma, CT-scans may be unnecessary outside the thoracoabdominal zone when chest X-ray is normal. In other cases, CT-scan seems to have an impact on the decision-making. In case of thoracoabdominal wounds, CT-scan helps to detect intra-abdominal injuries. The performance of CT-scan to diagnose TDI is not high enough to reliably rule out all TDI.
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Abstract
Video-assisted thoracoscopic surgery can be a useful tool in selected penetrating chest trauma patients for diagnostic and therapeutic purposes. It is currently a safe and feasible alternative to thoracotomy in the management of chest trauma especially for hemodynamically stable patients. Penetrating chest trauma with retained bullet was removed successfully in a 25 years old patient using double-port VATS technique in combination with fluoroscopy, he made full recovery, hospital stay was very short.
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Affiliation(s)
- Yasser Aljehani
- Corresponding author at: P.O. Box 40141, Al Khobar 31952, Saudi Arabia.
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Nevins EJ, Moori PL, Smith-Williams J, Bird NTE, Taylor JV, Misra N. Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma? Eur J Trauma Emerg Surg 2018; 44:811-8. [PMID: 29564472 DOI: 10.1007/s00068-018-0937-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/03/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE The indications for pre-hospital resuscitative thoracotomy (PHRT) remain undefined. The aim of this paper is to explore the variation in practice for PHRT in the UK, and review the published literature. METHODS MEDLINE and PUBMED search engines were used to identify all relevant articles and 22 UK Air Ambulance Services were sent an electronic questionnaire to assess their PHRT practice. RESULTS Four European publications report PHRT survival rates of 9.7, 18.3, 10.3 and 3.0% in 31, 71, 39 and 33 patients, respectively. All patients sustained penetrating chest injury. Six case reports also detail survivors of PHRT, again all had sustained penetrating thoracic injury. One Japanese paper presents 34 cases of PHRT following blunt trauma, of which 26.4% survived to the intensive therapy unit but none survived to discharge. A UK population reports a single survivor of PHRT following blunt trauma but the case details remain unpublished. Ten (45%) air ambulance services responded, each service reported different indications for PHRT. All perform PHRT for penetrating chest trauma, however, length of allowed pre-procedure down time varied, ranging from 10 to 20 min. Seventy percent perform PHRT for blunt traumatic cardiac arrest, a procedure which is likely to require aggressive concurrent circulatory support, despite this only 5/10 services carry pre-hospital blood products. CONCLUSIONS Current indications for PHRT vary amongst different geographical locations, across the UK, and worldwide. Survivors are likely to have sustained penetrating chest injury with short down time. There is only one published survivor of PHRT following blunt trauma, despite this, PHRT is still being performed in the UK for this indication.
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Abstract
This article discusses the role of radiology in evaluating patients with penetrating injuries to the chest. Penetrating injuries to the chest encompass ballistic and nonballistic injuries and can involve superficial soft tissues of the chest wall, lungs and pleura, diaphragm, and mediastinum. The mechanism of injury in ballistic and nonballistic trauma and the impact the injury trajectory has on imaging evaluation of penetrating injuries to the chest are discussed. The article presents the broad spectrum of imaging findings a radiologist encounters with penetrating injuries to the chest, with emphasis on injuries to the lungs and pleura, diaphragm, and mediastinum.
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Affiliation(s)
- Anthony M Durso
- Department of Radiology, Jackson Memorial Hospital/Ryder Trauma Center, University of Miami Miller School of Medicine, 1611 Northwest, 12th Avenue, WW-279, Miami, FL 33136, USA
| | - Kim Caban
- Department of Radiology, Jackson Memorial Hospital/Ryder Trauma Center, University of Miami Miller School of Medicine, 1611 Northwest, 12th Avenue, WW-279, Miami, FL 33136, USA
| | - Felipe Munera
- Department of Radiology, Jackson Memorial Hospital/Ryder Trauma Center, Radiology Services, University of Miami Hospitals, University of Miami Miller School of Medicine, 1611 Northwest, 12th Avenue, WW-279, Miami, FL 33136, USA.
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Soulat M, Carrié C, Cassone O, Thicoïpé MM, Revel P. [Prehospital ultrasound: time for a widespread use!]. Ann Fr Anesth Reanim 2014; 33:448-449. [PMID: 24907189 DOI: 10.1016/j.annfar.2014.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 04/29/2014] [Indexed: 06/03/2023]
Affiliation(s)
- M Soulat
- Samu/Smur, pôle des urgences adultes, groupe hospitalier Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France
| | - C Carrié
- Samu/Smur, pôle des urgences adultes, groupe hospitalier Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France.
| | - O Cassone
- Samu/Smur, pôle des urgences adultes, groupe hospitalier Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France
| | - M-M Thicoïpé
- Samu/Smur, pôle des urgences adultes, groupe hospitalier Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France
| | - P Revel
- Samu/Smur, pôle des urgences adultes, groupe hospitalier Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France
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Sochala M, Aïssou L, Sorbets E, Pop N, Sleiman C, Goudot FX, Meune C. Delayed cardiac tamponade following management of a massive hemothorax related to a penetrating thoracic trauma. Int J Cardiol 2014; 172:e69-70. [PMID: 24412463 DOI: 10.1016/j.ijcard.2013.12.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 12/21/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Maximilien Sochala
- Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, APHP, France
| | - Linda Aïssou
- Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, Université Paris XIII, APHP, France.
| | - Emmanuel Sorbets
- Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, APHP, France; Department of Cardiology, Bichat Hospital, Université Paris Diderot, APHP, France
| | - Natalia Pop
- Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, APHP, France
| | - Carla Sleiman
- Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, APHP, France
| | - François-Xavier Goudot
- Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, APHP, France
| | - Christophe Meune
- Department of Cardiology, Avicenne Hospital, Hopitaux Universitaires Paris-Seine-Saint-Denis, APHP, France; Department of Cardiology, Cochin Hospital, Université Paris Descartes, APHP, France
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Jeon K, Lim WH, Kang SH, Cho I, Kim KH, Kim HK, Kim YJ, Sohn DW. Delayed diagnosis of traumatic ventricular septal defect in penetrating chest injury: small evidence on echocardiography makes big difference. J Cardiovasc Ultrasound 2010; 18:28-30. [PMID: 20661334 DOI: 10.4250/jcu.2010.18.1.28] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 12/15/2009] [Accepted: 02/22/2010] [Indexed: 11/22/2022] Open
Abstract
Cardiac trauma from penetrating chest injury is a life-threatening condition. It was reported that < 10% of patients arrives at the emergency department alive. Penetrating chest injury can cause serious damage in more than 1 cardiac structure, including myocardial lacerations, ventricular septal defect (VSD), fistula between aorta and right cardiac chamber and valves. The presence of pericardial effusion (even a small amount) on the initial echocardiography might be the only clue to serious cardiac damage in the absence of definite evidence of anatomical defect in heart. We here present a case, in which clear diagnosis of VSD and pseudoaneurysmal formation was delayed a few days after penetrating chest injury due to the lack of anatomical evidence of damage.
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Affiliation(s)
- Kihyun Jeon
- Cardiovascular Center, Seoul National University Hospital, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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