Pulmonary embolism following pneumonectomy in blunt thoracic trauma

Abstract

1. Case reportA 31-year-old male sustained a severe crush injury to his chestafter being caught between a truck and loader. His admissioninjuries included: multiple left sided rib fractures with a left flailchest, pulmonary contusions, left main stem bronchus injury, leftpulmonary artery dissection, traumatic aortic disruption, lefthumerus and radius fractures and thoracic vertebral spinousprocess fractures (Fig. 1). After stabilisation and insertion of a leftthoracostomy tube, he underwent successful placement of anaortic endovascular stent graft. On admission bronchoscopy hewas found to have a laceration to the membranous portion of hisleft main stem bronchus without an obvious air leak. This wasinitially managed non-operatively. On post-admission day 2 hedeveloped progressive hypoxaemia, and bronchoscopy confirmedcomplete occlusion of his left main stem bronchus. The bronchialinjury and resultant obstruction was not amenable to endobron-chial stenting. Chest radiograph showed opacification of his leftlung(Fig.2).Atthoracotomyextensivetissuedestructioninvolvinggreater than 90% of his left main stem bronchus was found, andwas not repairable. A left pneumonectomy was performed.Ten days following pneumonectomy the patient developedacute respiratory failure and hypotension. Computed tomography(CT) identified a massive PE occluding the right main pulmonaryartery(Fig.3).Anemergentmultidisciplinaryconferencereviewedthe available options which included: sternotomy with cardiopul-monary bypass and pulmonary thrombectomy, peripheral extracorporeal membrane oxygenation for haemodynamic support andintravenous heparin and lastly catheter directed thrombolysis andplacement of an inferior vena cava (IVC) filter. Given the markedhaemodynamic instability of the patient, thrombolysis and filterplacement was chosen. Following thrombolysis the patientexperienced immediate and marked haemodynamic improve-ment. Systemic anticoagulation was initiated. Ultimately hisorthopaedic extremity injuries were corrected and he survivedto independent ambulatory discharge from the hospital.2. Discussion2.1. Pulmonary embolism in major blunt trauma and prophylacticinferior vena cava filtersSeverely injured patients are at high risk for both deep venousthrombosis (DVT) and subsequent PE with current estimates ofDVT incidence in trauma patients approximating 13% withprophylaxis and 38% without.