Massive Hemothorax Caused by a Single Intercostal Artery Bleed Ten Days after Solitary Minimally Displaced Rib Fracture.

Karleigh R Curfman,Sebastian D Schubl,Charles S Lapunzina,Ravi K Kothuru,Katherine D Gray,Gregory G Salzler,R Jonathan Robitsek

doi:10.1155/2015/120140

Karleigh R Curfman, Sebastian D Schubl + Show 5 more

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https://doi.org/10.1155/2015/120140

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Abstract

Delayed hemothorax (DHX) following blunt thoracic trauma is a rare occurrence with an extremely variable incidence and time to diagnosis that is generally associated with clinically insignificant blood loss. In this report, we present a case of acute onset DHX ten days after a relatively mild traumatic event that resulted in a single minimally displaced rib fracture. The patient awoke from sleep suddenly with acute onset dyspnea and chest pain and reported to the emergency department (ED). The patient lost over six and a half liters of blood during the first 9 hours of his admission, the largest volume yet reported in the literature for DHX, which was eventually found to be due to a single intercostal artery bleed. Successful management in this case entailed two emergent thoracotomies and placement of multiple thoracostomy tubes to control blood loss. The patient was discharged home on postoperative day 5.

Highlights

Delayed hemothorax (DHX) is a rare entity with many potential causative factors and an exact definition that has yet to be agreed upon, warranting further research
This case underscores that even patients that have comparatively minor chest trauma days or even weeks earlier are capable of developing life threating bleeding and should be managed in the same manner as acute chest injuries if the clinical presentation is suspicious
Indications for emergent thoracotomy should be no different compared to in trauma patients that present at the time of injury, though there are options for noninvasive angiographic techniques in stable patients

Summary

Introduction

Delayed hemothorax (DHX) is a rare entity with many potential causative factors and an exact definition that has yet to be agreed upon, warranting further research. In one retrospective study spanning two years, 11 of 515 cases of blunt thoracic trauma developed delayed hemothorax, an incidence of 2.1% [2]. A study by Misthos et al reported an incidence of 7.4% over two years, with 52 out of 709 blunt thoracic trauma patients developing delayed hemothorax [4]. We report a unique case of both an exceptionally large and extraordinarily delayed hemothorax, namely, a 6.5liter acute blood loss that occurred ten days after the inciting incident. A PubMed query revealed only five publications on DHX that reported cases presenting at ten days or later, and none had a blood loss of similar volume to that observed in our patient [1, 4, 6–8]

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