Chest Wall Hematoma Research Articles

Chest Wall Hematoma after Continuous Serratus Anterior Plane Block.

Chest Wall Hematoma after Continuous Serratus Anterior Plane Block.

Delayed chest wall hematoma complicated by infection and osteomyelitis of the rib: A case report and brief review

Delayed chest wall hematoma complicated by infection and osteomyelitis of the rib: A case report and brief review

Percutaneous thrombin injection under contrast-enhanced ultrasound guidance to control active extravasation not associated with pseudoaneurysm.

The technique of percutaneous thrombin injection (PTI) under contrast-enhanced ultrasound (CEUS) guidance for control of acute hemorrhage-active extravasation not associated with pseudoaneurysm is demonstrated in three cases: 1) Massive spontaneous retroperitoneal hematoma in a patient with multiple comorbidities. Contrast-enhanced computed tomography (CT) showed extensive active extravasation, which was only partially controlled by transarterial embolization. CEUS was performed in the angiography suite. Contrary to unenhanced US and colour Doppler US (CDUS), CEUS confirmed persistent extravasation; CEUS-guided PTI was performed immediately thereafter. 2) Large rectus sheath hematoma in a patient on anticoagulant therapy. Contrast-enhanced CT and unenhanced US/CD could not definitely diagnose extravasation. CEUS clearly showed extravasation and was used for guidance of PTI. 3) Chest wall hematoma complicating central venous catheter placement in a patient with coronavirus on anticoagulant therapy. CDUS was inconclusive. CEUS was performed at the bedside, clearly showed active extravasation, and was used for guidance of PTI. In all three cases, post-PTI CEUS confirmed the absence of residual enhancement of the hematomas, and the hemodynamic status of the patients improved. PTI appears to be effective in selected cases of hematomas associated with active extravasation. In this context, CEUS may be the most suitable modality for guidance and for an immediate evaluation of the treatment effect.

A case report of dengue hemorrhagic fever complicated by anterior chest wall haematoma requiring blood transfusion which later progressed to hepatic encephalopathy

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Thoracic paravertebral block vs mid-point transverse process to pleura block in thoracic surgery. Preliminary evaluation of effectiveness and safety

Mid-point Transverse process to Pleura Block (MTPB) is an alternative approach to paravertebral block. We retrospectively assessed hemodynamic stability, inadvertent pleural puncture and antalgic effectiveness of this approach compared with traditional paravertebral block. Moreover, being used to add methylene bleu to local anesthetic solution as a tracer, we compared the diffusion pattern in paravertebral space of the two techniques. We reported retrospectively 40 patients underwent lung lobectomy from July to October 2021 in Monaldi Hospital (Naples, Italy) receiving thoracic paravertebral block (n=20) or mid-point transverse process to pleura block (n=20). The primary outcomes were a 20% mean arterial pressure variation from the base line, chest wall or pleural hematoma and technique failure. Analgesic effectiveness was assessed comparing remifentanil consumption to keep nociception index level < 25 and patient’s VAS in post anesthesia care unit or daycare surgical unit at 60’. Also the methylene blue spread was assessed by a surgeon, blinded to patient’s name reviewing surgery videorecord of every cases. MAP decrease > 20% was greater in the TPVB. No significative differences were reported for pleural punctures, chest wall hematomas or failure of the technique in the two groups. Methylene blue was evident in all patients of the TPVB, while it was not visible in any of the patients of the MTPB group. Remifentanil consumption, nociception index level and postoperative 60’ VAS were greater in the MTPB.Antalgic power and local anesthetic spread of TPVB seems to be superior to the MTPB, even if the safety profile of the latter seems to be better. Due to the retrospective nature of the study and the small number of cases in the sample, further studies are needed.

Single-center experience of temporary-permanent pacemaker use in COVID-19 patients supported with veno-venous ECMO: A case series.

In the first year of the COVID-19 pandemic, nine out of 129 patients (7%) developed life-threatening bradycardia episodes ultimately requiring a TPPM, whilst being supported with VV-ECMO for severe COVID-19 ARDS in our tertiary cardio-pulmonary failure center. All subjects had asystole due to sinus node dysfunction and experienced at least one episode involving cardiopulmonary resuscitation. Most bradycardic events were seen in the context of vagal hypersensitivity. Mean time from general ICU admission to TPPM insertion was 20.6 ± 8.9days. One patient developed a large chest wall hematoma weeks after TPPM implantation, no other TPPM-related issues were observed. No patient required a long-term pacing system. Six-months survival rate was high (89%). These findings suggested that transient life-threatening sinus node disease is not uncommon in ECMO-dependent COVID-19 ARDS patients. TPPM with an active fixation lead is sometimes needed to facilitate ongoing ICU care, however, long-term permanent pacing was not required.

Pilot clinical study on the prevention of complications after lung biopsy by the MIPP kit PNX device.

Pneumothorax (PNX), pulmonary hemorrhage, hemothorax and chest wall hematoma are the most commonly reported complications of percutaneous lung biopsy (PLB). Sealing the biopsy tract with different types of materials is an emerging way to prevent PLB complications. To investigate the safety and efficacy of a new device, Minimally Invasive Percutaneous Procedure Kit for Pneumothorax (MIPP-Kit PNX), when used in association with a resorbable bio-compatible glue in the prevention of PLB complications. A prospective, multicenter, open-label, single-arm study was performed to evaluate the complication rate after glue administration by the new investigational device during PLBs. Fourty-three patients were enrolled after informed consent signature (40 underwent PLB, while three were screening failures). Only 3 patients (7.5%, 95% CI: 0.0-15.7%) developed complications within 48 h after glue injection during PLB: two developed minor pneumothoraces and one a pulmonary hemorrhage. No patients who showed procedural complications before glue administration were reported with any recurrent or new complications after glue administration. In comparison with the data reported in the literature, this trial results support the safe and effective use of the MIPP kit PNX in the prevention of PLB complications. These promising preliminary results warrant further confirmation in larger clinical trials. ClinicalTrials.gov identifier: NCT04071509.

Delayed dorsal scapular artery hematoma following blunt thoracic trauma: a case report and review of the literature

BackgroundThe present case contributes to the limited literature on delayed chest wall hematomas following blunt trauma. The literature review provides a summary of similar previously reported cases.Case presentationWe report the case of a 59-year-old Caucasian male who presented to the emergency department with a rapidly expanding chest wall hematoma. Six weeks earlier, he had sustained multiple rib fractures and a pneumothorax after falling 4 m from a ladder. Computed tomography angiography was used to identify two sources of active bleeding on the left dorsal scapular artery. The patient underwent surgery with evacuation of the hematoma and ligation of the artery. The patient was hospitalized for 3 days and recovered with no sequelae.ConclusionsA literature review revealed eight previously reported cases of chest wall hematomas exterior to the endothoracic fascia following blunt trauma. Most cases were initially diagnosed by computed tomography of the chest and finally by angiogram. Management options range from surgical drainage to angiographic embolization. This case is unusual regarding the delay in the development of the hematoma and illustrates the importance of considering this diagnosis even weeks after relevant trauma.

Misdiagnosed desmoid fibromatosis of the chest wall presenting in emergency like as recurrence of post-traumatic hematoma: A case report and review of the literature

Introduction and importanceDesmoid Fibromatosis (DF) represents a rare neoplasm developing from fascial and musculoaponeurotic structures. Preoperative diagnosis of DF is a challenge because of its rarity and nonspecific presentation. Imaging may be helpful for determining the correct diagnosis. Currently there are different clinical treatments of DF including surgical treatment, drug treatment and radiotherapy.Case presentationA 43-year-old Caucasian male presented to the Emergency Department with a 6-month history of recurrence of post-traumatic chest wall hematoma. Physical examination revealed a partially solid, painless mass on the right anterior chest wall. Laboratory tests reported and neutrophilic leukocytosis. Thoracic contrast-enhanced computed tomography showed a smooth contour, heterogeneous and hypodense subcutaneous soft tissue mass anterior to the right pectoral muscles and to the right 4th–7th rib. The patient underwent surgery: a solid suprafascial neoplasm was completely excised. The postoperative course of the patient was uneventful.Clinical discussionDF is a soft tissue neoplasm with a tendency for local invasion and recurrence. The course of DF cannot be predicted, being fatal if DF infiltrates vital structures. Diagnosis of DF is difficult and imaging may be helpful for determining the correct diagnosis. Currently the treatment for DF has shifted from surgery (post-operative recurrence rates of 20%–70%) to conservative therapy including watchful waiting.ConclusionDF is a myofibroblastic proliferative soft tissue tumor and classified as an intermediate malignancy. Preoperative diagnosis of DF needs a high index of suspicion and is facilitated by imaging. Surgery, among different treatments, represents a potentially curative treatment of DF.

711 Atypical Presentation of a Ruptured Thyroid Cyst

Abstract Introduction Thyroid cysts are a common finding with the bulk of cases being benign and approximately only 5% being malignant. The majority of these cysts are managed conservatively in the absence of malignancy or compressive symptoms. Case presentation A middle-aged female patient presented with sudden onset anterior neck bruising but minimal specific symptomatology. On examination, the patient had bruising around the anterior neck and chest wall. CT and MRI scanning of the neck revealed the bruising was attributed to a ruptured thyroid cyst. On follow up, an ultrasound guided fine-needle aspirate revealed the histology to be inflammatory follicular thyroid tissue. D iscussion The case demonstrated a rare presentation, given the lack of trauma in her history nor the presence of more sinister conditions as demonstrated by the fine-needle aspirate. Normally hemorrhage of thyroid cysts are due to trauma or abnormal thyroid vasculature. There are a few previous case reports of similar presentations where ruptured thyroid cysts led to life-threatening airway compromise requiring intubation. Early recognition of these thyroid cyst complications is crucial. Conclusion Neck and anterior chest wall hematoma can be a sign of thyroid cyst rupture/hemorrhage. It is important to recognize this sign to prevent life-threatening airway compromise.

Two Cases of Spontaneous Bleeding in Lung Transplant Recipients Treated with Systemic Anticoagulation for COVID-19

IntroductionCOVID-19 promotes inflammation and a hypercoagulable state. Antithrombotic therapies may be administered for thromboprophylaxis in those with severe infection requiring hospitalization. Spontaneous bleeding is an infrequent, yet life-threatening complication in patients receiving systemic anticoagulation.Case ReportTwo bilateral lung transplant recipients - 77-year-old female with idiopathic pulmonary fibrosis (patient A) and 69-year-old male with chronic obstructive pulmonary disease (patient B) - each presented with several days’ history of dyspnea, cough, and fatigue at 29-months and 11-months post-transplant, respectively; RT-PCR was positive for SARS-CoV-2 infection in both. Over the course of the next few days, patient A rapidly deteriorated with need for intubation despite initial treatment with antibiotics and corticotherapy. Patient B experienced gradual worsening of respiratory symptoms, which required high-flow oxygen supplementation and IV antibiotics. Inflammatory markers were elevated in both patients, and CT of the chest was consistent with atypical pneumonia in each. Patient A received convalescent plasma as a rescue therapy, and patient B received remdesivir with convalescent plasma. Given the hypercoagulable state in each, patient A and B received enoxaparin and IV heparin, respectively. Slowly, hemoglobin and platelet counts dropped in both patients, with need for transfusion and hemodynamic support. CT of the abdomen revealed a left gluteal intramuscular hematoma in patient A; CT of the chest, abdomen, and pelvis revealed a spontaneous chest wall hematoma and small area of retroperitoneal bleeding in patient B (Figure 1A and B).SummaryThese cases raise awareness for the viral-induced hypercoagulable state observed during the disease course. Clinicians should be cautious to avoid any hemorrhagic complications associated with thromboprophylaxis in selected cases, particularly in at-risk immunosuppressed patients.

Thromboprophylaxis causing spontaneous bleeds in COVID patients

COVID-19 is an ongoing pandemic that was identified in December 2019 in Wuhan, China. Patients admitted to the hospital with COVID-19 present with many coagulation abnormalities, precipitating a hypercoagulable state which exposes them to thrombosis for which they receive thromboprophylaxis therapy with enoxaparin. Over the course of this therapy, some patients develop spontaneous bleeding episodes in different regions of the body of varying degrees and sometimes require radiological angioembolisation to control the bleed. This case series sheds light on three patients who were admitted in Rashid Hospital, Dubai, UAE, with COVID-19 and developed spontaneous bleeds. Amongst the three patients, two of them developed retroperitoneal bleed and one patient developed a chest wall haematoma. One of them underwent radiological intervention (angioembolisation), while the other two underwent conservative management and were monitored for haemodynamic changes. There are limited studies demonstrating the correlation between high dose of enoxaparin and bleeding episodes amongst COVID-19 patients. However, we advise the need for further guidelines and data to advocate the relation between enoxaparin and bleeding episodes.

First case of cough-induced combined intercostal artery rupture with partial diaphragm tear

We describe a case of vigorous cough-induced left intercostal artery rupture with partial diaphragmatic tear in a 60-year-old obese male with chronic obstructive pulmonary disease. He presented with left hemothorax, a rapidly spreading chest and abdominal wall hematoma, and progression of anemia. Computed tomography (CT) scan revealed a bleeding focus from the left 8th intercostal artery. CT-guided surface marking of the bleeding point was done over the chest wall. The patient underwent open thoracotomy with drainage of clotted hemothorax and ligation of bleeding intercostal artery. Incidentally, a partial diaphragm tear was detected during the surgery which was repaired. The combined presentation of cough-induced intercostal artery rupture with partial diaphragm tear is not reported earlier. Awareness of these co-existing pathologies can facilitate timely diagnosis and appropriate life-saving management.

Spontaneous chest wall haematoma in chronic myeloid leukaemia

Chronic myeloid leukaemia can have different presenting signs. Here, we present a case of nontraumatic spontaneous chest wall haematoma in an 84-year-old man under investigation for myeloproliferative disorder before his admission. He was admitted with a 2-day history of sudden onset posterior chest wall pain and progressive bruises. Computed tomography showed a chest wall haematoma, while blood tests found a mild coagulation abnormality. He required fresh frozen plasma and red blood cell transfusions as part of his management, but his symptoms improved after starting hydroxycarbamide.

The Safety of Ultrasound-Guided Thoracentesis in Patients on Novel Oral Anticoagulants and Clopidogrel: A Single-Center Experience

ObjectiveTo assess the risk of hemorrhagic complications in patients taking novel oral anticoagulants (NOACs) and/or clopidogrel who underwent an ultrasound-guided thoracentesis. Patients and MethodsA retrospective analysis was performed of ultrasound-guided thoracenteses completed at an academic institution between January 1, 2016, and November 14, 2017. All patients who underwent a thoracentesis while actively receiving treatment with an NOAC and/or clopidogrel were included in the study. Primary endpoints are any significant post-procedure bleeding complication; defined as a hemoglobin decrease of greater than 2 g/dL in 48 hours, hemothorax, chest wall hematoma, and bleeding requiring transfusion, surgery, or chest tube placement. ResultsA total of 115 thoracenteses were performed in 103 patients actively taking an NOAC (n=43) and/or clopidogrel (n=69). All patients used either the NOAC or clopidogrel within 24 hours before the procedure and continued using it daily thereafter. There were no bleeding complications. ConclusionThe overall risk of significant hemorrhage in patients taking an NOAC and/or clopidogrel while undergoing ultrasound-guided thoracentesis is very low. Albeit the total number of procedures reviewed may be insufficient to prove definitive safety, it is sufficient to provide a measure of relative risk when assessing benefits of thoracentesis in these patients.

Gemella Morbillorum: A Rare Cause of Empyema Necessitans

SESSION TITLE: Lung Infections 2 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 30, 2017 at 11:00 AM - 12:00 PM INTRODUCTION: Empyema necessitans is a rare condition that arises when pus from the pleural cavity penetrates through the adjacent tissues to form a chest wall abscess. It can occur in the setting of delayed treatment of pleural infections. We present a case of empyema necessitans as a result of suspected chest wall trauma. CASE PRESENTATION: A 59 year old female was referred to the hospital by her pulmonologist after an incidental finding of a right lower lobe pulmonary embolism, right chest wall hematoma, and a right upper lung effusion on computed tomography (CT) scan of the chest. One month prior she had suffered a fall and developed progressively worsening dyspnea. She denied any fevers, chills, chest wall swelling, pain, or skin abrasions. Prior to the initiation of anticoagulation, a thoracentesis was performed to rule out a hemothorax. Imaging also noted a communication between the pleural effusion and a collection in the anterior chest wall. Thick purulent material was noted on CT guided thoracentesis and drainage of the chest wall abscess. A chest tube was placed in the pleura and a pig tail drain in the chest wall. The patient was empirically started on piperacillin-tazobactam. Microbiological studies from the pleural fluid and thoracic abscess were positive for Gemella morbillorum. The chest tube and pig tail drain were removed after 4 days when resolution of the empyema and chest wall abscess were noted. The patients dyspnea resolved and the patient was discharged on a 14 day course of Doxycycline. DISCUSSION: On review of the literature, most reported cases of empyema necessitans were caused by Mycobacterium tuberculosis, Actinomyces israelii, Streptococcus pneumoniae, Staphylococcus aureus, and Pseudomonas cepacia. Gemella morbillorum is a Gram-positive coccus which naturally inhabits the human oropharyngeal, gastrointestinal, and urogenital flora. However, it is infrequently isolated and rarely results in pleural infections. Additionally, chest wall trauma is a rarely reported inciting factor for an empyema necessitans. CONCLUSIONS: Our case highlights a rare occurrence where Gemella morbillorum was the causative agent of an empyma necessitans secondary to chest wall trauma. This brings to light that rare causes must be considered in the investigation of an empyema necissitans. Reference #1: Kono S, Nauser T. Contemporany empyema necessitatis. Am J Med. 2007;120:303-5. Reference #2: Benedetti P, Rassu M, Branscombe M, Sefton A, Pellizzer G. J. Med. Microbiol. 58(12):1652-1656 doi:10.1099/jmm.0.013367-0 DISCLOSURE: The following authors have nothing to disclose: Sohi Ashraf, Animesh Gour, Santhosh John, Shalinee Chawla No Product/Research Disclosure Information

Thrombin Injection to Treat an Iatrogenic Internal Mammary Artery Pseudoaneurysm

A 71-year-old female presented to the emergency room eight weeks status post open heart surgery for aortic valve replacement with right-sided chest wall pain and swelling. Computed tomographic (CT) angiography demonstrated a hyperattenuating structure arising from the right internal mammary artery surrounded by a heterogeneously-attenuating fluid collection in the anterior right chest wall, compatible with a right internal mammary artery pseudoaneurysm with surrounding chest wall hematoma. Follow up color Doppler ultrasound confirmed the diagnosis. Under direct ultrasound visualization, we injected four hundred units of thrombin into the neck of the pseudoaneurysm using a 25-gauge spinal needle. Post-injection imaging demonstrated a successful cessation of flow within the pseudoaneurysm sac.

Complications of thoracentesis: incidence, risk factors, and strategies for prevention.

Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema. Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study. Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.

胸郭内に進展した急性特発性胸壁血腫の1例

症例は64歳，男性．左背部痛を主訴に近医を受診，胸部X線写真・胸部CTで左胸水を認め，膿胸が疑われ当科紹介となった．当院の胸部CTでも膿胸が疑われ胸腔ドレナージを開始した．胸水は淡血性であったが膿性ではなく，ドレナージ後も左上中肺野の陰影は残存した．発熱もなく炎症反応も軽度であり膿胸以外の血腫や腫瘍性疾患も考慮し，診断治療目的で胸腔鏡下手術を施行した．胸腔内所見では，胸腔内に血腫は認めず壁側胸膜に約14cmの膨隆を認めた．壁側胸膜を切開すると凝血塊が充満しており，胸壁血腫と診断した．膨隆部の壁側胸膜を切除し凝血塊を掻爬したが，明らかな出血点は確認できなかった．術後経過は良好で，術後14日目に退院となった．発症前に手術，外傷の既往はなく抗凝固剤の服用もなく出血傾向の素因は認めなかった．われわれが検索しえた範囲では，胸郭内に腫瘤を形成した急性特発性胸壁血腫の報告はなく，極めて稀な症例と思われたので報告する．

Traumatic lateral abdominal wall hematoma treated with Kampo medicines

ABSTRACTCaseA 62‐year‐old woman presented with whiplash, bruised chest, and lateral abdominal wall hematoma with an arterial rupture. Keishibukuryogan (KBG), a traditional Japanese Kampo medicine, was administered for treatment of oketsu syndrome. Five days after the injury, cervical and chest pain were still present, and the subcutaneous hematoma had increased tremendously in size. KBG was discontinued and jidabokuippo (JDI) was administered. The subcutaneous hematoma improved dramatically.OutcomeSymptoms improved after treatment with JDI.Conclusion JDI can be used for the management of pain and swelling following abdominal wall hematoma as an alternative to non‐steroidal anti‐inflammatory drugs.