Massive Hemothorax Research Articles

Clinical efficacy of intraoperative Cell Saver autologous blood salvage in emergency surgery for massive hemothorax.

The objective of this study was to investigate the efficacy of intraoperative Cell Saver blood salvage during emergency surgery for massive hemothorax on minimizing perioperative allogeneic red blood cell (RBC) transfusion. Fourteen consecutive patients of massive hemothorax with more than 800cc of intrathoracic bleeding estimated by chest X-ray and/or chest computed tomography (CT) scan at presentation between 2009 and 2021 were retrospectively reviewed. Intraoperative Cell Saver blood salvage was performed in 11 patients (Cell Saver group) with a median volume of 820cc (range, 421-1700cc). The amount of perioperative allogeneic RBC transfusion in the Cell Saver group (median, 4 units) was significantly smaller than that in the non-Cell Saver group (median, 10 units) (P = 0.009). The volume of Cell Saver autologous transfusion in 6 patients without preoperative chest tube drainage (median, 1114cc) was significantly larger than that in 5 patients who had preoperative drainage (median, 660cc) (P = 0.0173). In conclusion, the utilization of intraoperative blood salvage in emergency surgery for massive hemothorax along with limiting the amount of preoperative chest tube drainage is an efficient strategy to minimize perioperative allogeneic RBC transfusion.

Case report: management of a massive hemothorax in a patient undergoing haemopoietic stem cell transplantation

Case report: management of a massive hemothorax in a patient undergoing haemopoietic stem cell transplantation

A case report of a sudden adolescent death from a rare cause: rupture of a saccular thoracic aneurysm complicating undiagnosed coarctation of the aorta

Introduction: Coarctation of the aorta is one of the most commonly encountered congenital heart diseases accounting for about 7% of the cases. With early childhood diagnosis and the development of corrective surgical intervention, undiagnosed aortic coarctation presenting as sudden and unexpected death is today a rarity. Fatal complications such as aortic rupture or dissection, endocarditis and ruptured cerebral aneurysm can arise when left untreated. We report a rare case of sudden death involving an adolescent female found to have an undiagnosed aortic coarctation at autopsy with a saccular thoracic aneurysm and hemothorax. Case description: A healthy 17-year-old girl was dead on arrival at the Emergency Department of a district hospital after collapsing at home following a short history of breathing difficulties. A forensic autopsy revealed massive left-sided hemothorax and a heretofore undiagnosed aortic coarctation with a pre-coarctation saccular thoracic aneurysm that has ruptured. On histology, the aneurysm wall was found to be deficient in tunica media with no evidence of dissection. Discussion and conclusion: The clinicopathology of coarctation-associated aneurysms will be discussed. Despite their rarity, the forensic pathologist should consider the likelihood of aortic coarctation when confronted with the unexpected finding of a ruptured thoracic aortic aneurysm in the young.

ТРАВМАТИЧНИЙ ПНЕВМОНІТ ВНАСЛІДОК ВІЙСЬКОВОЇ ТРАВМИ ГРУДНОЇ КЛІТКИ ЯК ФАКТОР РИЗИКУ ПНЕВМОНІЇ

The relevance of the problem of gunshot wounds and injuries as a result of the war with Russia continues to grow. Gunshot wounds and chest injury can cause several life-threatening conditions: bleeding, airway obstruction, tension pneumothorax with pericardial tamponade, open pneumothorax, massive hemothorax, chest dissection, tracheobronchial injury, diaphragm damage, myocardial injury, rupture thoracic aorta, esophageal damage and lung contusion. Lung contusion or traumatic pneumonitis is characterized by hemorrhage and swelling in the alveoli. This causes respiratory distress which develops 24 hours after lung injury, causing perfusion/ventilation mismatch by increasing pulmonary vascular resistance and decreasing lung compliance. From February 24, 2022 to February 18, 2023, in the Pulmonology Department of Volyn Regional Clinical Hospital, the rate of hospitalized military patients with chest injury due to mine-explosive wounds, shrapnel wounds, gunshot bullet wounds, and stub-cut wounds of the chest amounted to 19.3% of all pulmonary cases among military, admitted this year (n=88). Penetrating chest injury occurred in 41.1% of cases, nonpenetrating blunt chest injury (including behind armor blunt trauma) in 23.5 % of cases, chest trauma with soft tissue injury in 35.2 % of cases. Chest injury with fractured chest bones was detected in 47% of cases. In 52.9 % of cases, chest injuries and one stab-cut wound were on the side surface and chest, which was not protected by a bulletproof vest. Lung contusion or traumatic pneumonitis was observed in 70.5% of cases, including destruction in 29.4 %. Post-traumatic pneumonia was observed in 58.8 % of cases, that was caused by a non-hospital and hospital infection, pleurisy was observed in 17.6 % of cases. After chest injury, infiltrative-destructive pulmonary tuberculosis was detected in 5.8 % of cases and invasive pulmonary aspergillosis in 5.8 % of cases. Thus, the occurrence of a specific infection that can lead to destruction and aggravate destructive changes in the lung parenchyma should also be taken into account. Also, in 64.7 % of cases, metal, fragmentary, foreign bodies of the chest organs were found, and required further surgical removal. The article presents clinical cases of patients with chest injuries received as a result of military operations in Ukraine. Key words: traumatic pneumonitis, lung contusion, gunshot wound, chest injury, behind armor blunt trauma, pneumonia.

A case of spontaneous hemothorax causing massive pleural effusion following laparoscopic sleeve gastrectomy

Background: Pleural effusion is a rare complication of sleeve gastrectomy. It has many possible etiologies, including gastric leakage, gastropleural fistula formation, splenic abscess, and complications related to administered medications, such as spontaneous hemothorax secondary to anticoagulants. Case Presentation: An unusual case of a 46-year-old woman was reported, who was presented to the emergency room (ER) 10 days after laparoscopic sleeve gastrectomy complaining of dyspnea, chest pain, and dry cough for 4 days. Imaging confirmed massive pleural effusion on the left side. The patient showed improvement after intensive care unit (ICU) admission and drainage via the chest tube. Conclusion: Sleeve gastrectomies are associated with several complications. Low-molecular-weight heparin (LMWH) as prophylaxis for portal vein thrombosis leads to a spontaneous hemothorax. Unfortunately, computed tomography with contrast could not be performed because of vital instability. However, it was concluded that a massive spontaneous hemothorax occurred due to LMWH. The patient was admitted to ICU and underwent slow drainage of pleural effusion until complete recovery

Massive spontaneous hemothorax caused by benign solitary schwannoma

Massive spontaneous hemothorax caused by benign solitary schwannoma

Surgical Management of Sudden Intrathoracic Hemorrhage in Two Patients with Occult Diaphragmatic Injury and Rib Fracture

Background: A sudden massive hemothorax as the initial manifestation of delayed diagnosis of blunt occult diaphragmatic injuries is extremely rare. We report our experience with two cases of sudden massive thoracic hemorrhage treated surgically for occult blunt diaphragm injury. In the present study, we aimed to present the successful rescue of two cases of sudden massive thoracic hemorrhage due to occult blunt diaphragmatic injury during hospitalization by surgical treatment. Sudden massive hemothorax a few days after hospitalization as an initial manifestation of blunt mysterious diaphragm injury is extremely rare.

1300: TWO CASES OF MULTIPLE TRAUMA PATIENTS WITH SEVERE CHEST TRAUMAS TREATED STRATEGICALLY USING VV ECMO

Introduction: VV-ECMO is widely used for severe respiratory failure due to endogenous diseases. Alternatively, there is little experience with its use for chest traumas. In this report, we describe two cases of severe chest traumas in which VV-ECMO was introduced and saved the patient’s life. Description: Case 1: A man in his 20s was injured in a collision accident with a passenger car while riding on the rear seat of a motorcycle. He was diagnosed with multiple left rib fractures, left hemopneumothorax, bilateral lung contusions, thoracolumbar rupture fracture, and left humerus fracture. The patient was intubated, and a left thoracic drain was inserted. The respiratory condition of the patient worsened because of increased subcutaneous emphysema caused by bronchial injury and bleeding in the airway; therefore, VV-ECMO was introduced on the third day. The bronchial injury was healed conservatively, and the patient was weaned off from VV-ECMO on the 10th day after spontaneous respiration was eliminated during respiratory support with VV-ECMO. The patient was transferred to the hospital on the 42nd day. Case 2: A man in his 70s was injured when his chest was caught in a commercial elevator. He was diagnosed with bilateral hemopneumothorax, tracheobronchial injury, aortic injury, 5th thoracic vertebra dislocation, and multiple rib fractures. Tracheal intubation and bilateral thoracic drains were inserted, and TAE was performed for multiple vascular injuries, including the internal thoracic artery. The VV-ECMO was performed on the same day because of the patient’s massive hemothorax and worsening respiratory condition due to bronchial injury. Thoracic endovascular aortic repair, bronchial repair, and posterior thoracic fusion were performed with a sufficient respiratory support by VV-ECMO. Furthermore, the patient was weaned off from VV-ECMO on the 24th day. The patient was transferred to the hospital on the 53rd day. Discussion: These experiences demonstrated that ECMO is useful not only for endogenous diseases but also for chest traumas. Currently, there is no fixed opinion on the treatment strategies including surgeries and the anticoagulants use under VV-ECMO. Therefore, decisions must be made on a case-by-case basis.

902: A MIX OF FUNGI, AIR, BLEED, AND CLOTS WITHIN A LUNG

Introduction: Spontaneous hemothorax is a rare condition known to be associated with anticoagulation. We describe a case of fatal hemothorax associated with 2 different fungi that presented a therapeutic dilemma. Description: A 74-year-old female with past medical history significant for hyperhomocysteinemia secondary to MTHFR gene mutation, bioprosthetic aortic valve replacement, deep venous thrombosis, pulmonary embolism and paroxysmal atrial fibrillation on therapeutic anticoagulation presented with fever, dyspnea and hemoptysis. CT of the chest showed an actively extravasating left lung hematoma extending into the pleural space with moderate hemothorax and a small focus of gas within the collection and underlying multifocal pneumonia. Systemic anticoagulation was held and she received antibiotics for pneumonia despite which hypoxia worsened and she was intubated. She required pressors secondary to septic shock. She underwent multiple bronchoscopies and chest tube placement despite which she continued to have recurrent hemothorax suspected secondary to an actively hemorrhagic lung abscess. While in the operating room for video-assisted thoracoscopic surgery (VATS) she suffered cardiac arrest with return of spontaneous circulation in 2 minutes that resulted in multiorgan dysfunction. VATS was aborted. Cultures from previous bronchoscopy resulted in growth of Penicillium and Aspergillus species and she was started on antifungal therapy. However, she subsequently developed multiple pulmonary emboli and embolic brain infarcts. In light of clinical deterioration and grim prognosis, the family opted for comfort measures. Discussion: Despite its association with hemoptysis, there are limited studies describing the occurrence of massive spontaneous hemothorax in aspergillosis. Our case is made additionally interesting by the co-infection with Aspergillus and Penicillium species simultaneously. The patient’s hyperhomocysteinemia predisposes her to a prothrombotic state, compounded by atrial fibrillation that was likely the cause of multiple embolic infarcts in paradox to her actively hemorrhagic abscess that precluded systemic anticoagulation. The therapeutic dilemma and rapid clinical deterioration raise the need for further investigation into the condition to augment early diagnosis and intervention.

Spontaneous haemothorax caused by a ruptured pulmonary arterio-venous malformation: A manifestation of hereditary haemorrhagic telangiectasia in pregnancy.

We report our experience of managing a massive haemothorax caused by a ruptured, previously unknown, pulmonary arteriovenous malformation (pAVM) at 34 + 5 weeks of gestation, which proved to be a manifestation of hereditary haemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. The patient underwent an emergency caesarean section under general anaesthesia after placement of a chest tube and gave birth to a healthy infant. A postoperative thoracic computed tomography angiography highlighted the presence of the large pAVM. Transcatheter embolization was performed right after the delivery. Subsequent patient's anamnesis, family history and genetic analysis finally revealed the presence of the syndrome. The aim of our report is to create awareness of this serious condition with potential life-threatening complications, especially in pregnancy. Simple criteria have been published and allow to easily consider HHT and the presence of potential AVM during anamnesis, ideally even before pregnancy.

Hybrid surgery for blunt aortic injury with rupture: a case report

Blunt thoracic aortic injury is one of the most lethal traumatic injuries. Ruptured cases often result in cardiac arrest before arrival at the hospital, and survival is rare. A female patient in her 30s was struck by an automobile while she was walking across an intersection. She was in a state of shock when emergency services arrived and was in cardiac arrest shortly after arriving at the hospital. A left anterolateral thoracotomy revealed a massive hemothorax secondary to thoracic aortic rupture. In addition, the patient had multiple traumas, including maxillary, pelvic, and lumbar burst fractures. We attempted to directly suture the aortic lesion; however, the increasing blood pressure caused the suture to break. We used a thoracic stent graft while ensuring permissive hypotension. Her postoperative prognosis was positive, and she was transferred to another hospital 85days later. We successfully performed a hybrid surgery combining thoracotomy and endovascular repair for this emergency case of blunt thoracic aortic injury with rupture.

Pregnancy complicated by neurofibromatosis type 1 in a patient with a history of massive spontaneous hemothorax: a case report

Pregnancy complicated by neurofibromatosis type 1 in a patient with a history of massive spontaneous hemothorax: a case report

CTガイド下肺生検術で大量血胸に至り緊急手術を要した1例

CTガイド下肺生検術で大量血胸に至り緊急手術を要した1例

Polytrauma with Grade-IV Liver Laceration and Grade-II Renal Laceration: A Case Report

Background: One of the leading causes of mortality and morbidity is road accidents. The commonest cause of polytrauma is due to road traffic accidents, other causes may include self-harming activities, suicide, and murder. Nearly two- thirds deaths due to Road Traffic accidents are reported in India mostly in the age group of 15-44 years. Rescue of patients with polytrauma requires maintaining hemostasis while concurrently administering treatments and using proper triage management according to the severity of the injuries, especially in situations of severe trauma with pulmonary contusion and significant blood loss. Massive hemothorax and extensive tracheobronchial hemorrhage result from serious lung injury. Depending on the amount of chest leakage in cases with hemothorax, emergency surgery is advised. Here we report a case of a 20-year-old adult male who was brought by his parents to the emergency department in a conscious state. The patient reported sustained injuries over the face, chest, and left knee. All the necessary laboratory investigations were done after which the patient was shifted to the Surgery Intensive Care Unit. The primary therapeutic intervention was given to the patient and was treated with blood transfusion, antibiotics, antiemetics, and antacids, and a diet was planned during hospitalization.

Isolated left atrial rupture following blunt chest trauma

Pediatric blunt cardiac rupture (BCR) is uncommon in the pediatric population and is associated with a high mortality rate. Isolated Left atrial chamber rupture following low impact blunt chest trauma is a very rare form of BCR. This report presents a 3 year old boy who presented with hemorrhagic shock and a massive left hemothorax following the fall of a table top on his chest. The patient underwent urgent left antero-lateral thoracotomy, with cardiopulmonary bypass, and the injury was successfully repaired. Based on our literature review, the isolated left atrial rupture after blunt chest trauma is extremely rare. A high level of suspicion should be maintained for early diagnosis and management. The typical findings are hemorrhagic shock with cardiac tamponade or massive hemothorax. The use of cardiac bypass and auto-transfuser can greatly assist in the speed of resuscitation. Further research might help in assessing the benefit in using bypass on survival on this subset of trauma cases.

Spontaneous Tension Hemothorax in a Patient with Asbestosis.

A 75-year-old man with a history of asbestosis presented to the emergency department with sudden-onset dyspnea and hemoptysis, triggered by coughing. The patient was hemodynamically unstable and in respiratory distress. Computed tomography revealed a massive hemothorax on the left side and compression of the descending thoracic aorta. He underwent emergency surgical exploration after decompression by chest tube insertion. The hemothorax was caused by tears in the pleural adhesions due to asbestosis and induced by coughing. Spontaneous hemothorax is a rare subtype of hemothorax. There have been only a few case reports of spontaneous tension hemothorax. In addition to its typical findings, compression of the thoracic descending aorta was observed in our patient. We hypothesize that severely diminished pulmonary compliance contributed to the extremely high intrathoracic pressure, which led to this unusual finding.

Modern treatment of massive hemothorax

Introduction and objective: Hemothorax is an umbrella term for pathologies with an extremely wide range of etiology and severity. Most commonly it is of tramuatic origin, frequently iatrogenic (intervention, blood coagulation altering therapy) and rarely unknown. Depending on the cause, volume, and dynamics, it requires a patient-adapted treatment determined by access to certain therapeutical methods. We aim to provide a practical overview of these. Methods: Retrospective analysis of patients treated for haemothorax at the Thoracic Surgery Department of Borsod-Abaúj-Zemplén County Teaching Hospital in the period 1 January 2017–31 December 2021 has been performed. We used the hospital’s database to collect data. In this paper, we analyze the cause of hemothorax, method of treatment, the efficacy of chosen therapeutic modality, duration of hospital stay, complication rate, 30-day survival. Results: 77 patients were treated with hemothorax, 57 male, 20 female patients. Average age was 53,4 (23–90, SD:14,9) years. Surgery was performed in 31 cases, with 10 cases needing reintervention. In 7 cases, multimodal approach was chosen, with chest wall stabilization. Average hospital stay: 14 (2–79) days. 30-day survival: 95%. Discussion: Thoracic drainage is our first therapeutic choice. The methods used in the treatment of hemothorax in our practice have been extended with the use of digital subtraction angiography (DSA), which yields immediate and effective bleeding control. We performed video-assisted thoracoscopic surgery (VATS) in increasing numbers. Conclusions: As long as the intensity of bleeding and patient’s general status allows it, after drainage, the first therapeutic option – when accessible – should be DSA bleeding control. In cases which do not resolve after drainage, VATS evacuation of hematoma is a safe method used in the treatment of hemothorax. In the past 5 years, we used thoracoscopy in increasing numbers while treating this entity. Based on our results and the literature, we can safely state that the use of thoracoscopy in the treatment of hemothorax is a safe and reliable option in eligible patients, and the results are comparable with those treated by thoracotomy.

Incidence and Predictive Factors of Massive Hemothorax Due to Thoracic Vertebral Fractures.

Massive hemothorax due to thoracic vertebral fractures (MHTVF) is a potentially lethal condition; however, its epidemiological and clinical data have been rarely described. Thus, in this study, we aimed to evaluate the incidence, predictive factors, and clinical features of MHTVF. This retrospective cohort study enrolled 202 consecutive patients (136 male and 66 female patients) with thoracic vertebral fractures treated at our institute between January 2009 and December 2019. Their mean age was 60.7 (range, 17-90) years. Unstable fractures accounted for 57.4% (n=116) of the total fractures. The patients were then divided into MHTVF and non-MHTVF groups. We assessed the following MHTVF-associated factors: sex, age, history of medical conditions, anticoagulation/antiplatelet drug use, injury severity score, anatomical distribution of levels of the vertebral fractures, fracture type, and presence or absence of diffuse idiopathic skeletal hyperostosis (DISH) fracture. In total, eight patients (six men and two women) with a mean age of 68.9 years (range, 22-85 years) were determined to exhibit MHTVF. The incidence of MHTVF in patients with unstable thoracic spinal fractures was 6.9%, whereas none of those with stable spinal fractures exhibited MHTVF. Factors like type B (p=0.049) and DISH (p=0.017) fractures were noted to be significantly associated with the MHTVF. Three patients experienced shock upon arrival, whereas two exhibited delayed shock. Chest tube insertion and/or emergency thoracotomy was performed. The survival rate was 100.0%. MHTVF is not rare. Because type B and DISH fractures are identified as predictive factors of MHTVF, it must be carefully treated to avoid preventable death even after hospitalization in patients with these thoracic fractures.

Could video-assisted thoracoscopic surgery be feasible for blunt trauma patients with massive haemothorax?

IntroductionThe study reviewed the experience of video-assisted thoracoscopic surgery (VATS) for the treatment of massive haemothorax (MHT). Materials and MethodsAll adult patients who sustained blunt trauma with a diagnosis of traumatic haemothorax or pneumothorax (ICD9 860; ICD10 S27.0–2), injury to the heart and lungs (ICD9 861; ICD10 S26, S27.3–9), and injury to the blood vessels of the thorax (ICD9 901; ICD10 S25) were queried from the trauma registry between 2014 and 2018. Patients who had chest tube drainage amounts meeting the criteria for MHT and who underwent subsequent operations were eligible for analyses. The patients were divided into VATS or thoracotomy groups based on the surgical modalities. Descriptions and analyses of the two groups were made. ResultsThirty-eight patients were enroled in the study, including 8 females (21%) and 30 males. The median age was 47.0 (first quartile (Q1) 25.5 and third quartile (Q3) 59.3) years. Twenty-three patients were in the VATS group, six (26%) of whom were converted to thoracotomy. There were no obvious differences in age, sex, pulse rate, or systolic pressure on arrival to the ED or after resuscitation between the two groups. The laboratory data were worse amongst the thoracotomy group, especially the arterial blood gas analysis (ABG) results: pH 7.2 (7.1, 7.3) vs. 7.4 (7.2, 7.4); HCO3 14.6 (12.4, 18.7) vs. 19.7 (16.1, 23.9) mEq/L; base excess (BE) -12.6 (-15.8, -7.8) vs. -5.2 (-11.1, -0.9) mEq/L. The PaO2/FiO2 ratio was lower in the thoracotomy group (91.4 (68.5, 193.3) vs. 245.3 (95.7, 398.0) mmHg). The thoracotomy group had coagulopathy (INR 1.6 (1.2, 1.9) vs. 1.3 (1.1, 1.4)) and required more blood transfusions (WB and PRBC 36.0 (16.0, 48.0) vs. 12.0 (4.0, 24.0) units; FFP 20.0 (6.0, 50.0) vs. 6.0 (2.0, 20.0) unit). No factors associated with VATS conversion to thoracotomy could be identified. ConclusionsVATS could be applied to selected blunt trauma patients with MHT. The major differences between the VATS and thoracotomy groups were coagulopathy, acidosis, PaO2/FiO2 ratio < 200 mmHg, or a persistent need for blood transfusion.

Emergency Thoracic Surgery in Chest Trauma at the Komfo Anokye Teaching Hospital in Ghana: The Role of Sternotomy and Thoracotomy

Objective: Chest trauma, as blunt or penetrating injury, account for significant amount of all traumatic injuries. They are associated with high mortality of about 75% of all trauma-related deaths, either from direct or indirect consequence of the injury. Nearly 80-85 % of chest trauma is managed conservatively with only about 10-15 % needing emergency surgery.Methodology: A retrospective cohort study of patients presenting with chest trauma and undergoing emergency thoracic surgery at the Komfo Anokye Teaching Hospital from January 2015 to June 2020 was carried out.Results: There were 29 patients, with 82.8% (24) being males. The mean age was 33.8 ± 15.0 years with range of 5-65 years. The leading mechanism of chest trauma was penetrating chest injury, which accounted for 51.7% (15). Eighteen (86%) patients underwent exploratory thoracotomy with 5 (10%) having exploratory sternotomy and the remaining 4% undergoing other procedures. Fourteen (82.1%) patients out of the eighteen who underwent the thoracotomy had a left thoracotomy with four (24.1%) patients having right thoracotomy. The major indication for surgery in acute thoracic trauma was traumatic diaphragmatic rupture (62.1%) followed byimpalement injury (17.2%), traumatic thoracotomy (6.9%), cardiac tamponade (6.9%), massive haemothorax (3.5%), and vascular injury (3.5%). There were no mortality over the 5-year period.Conclusion: The leading indication for emergency thoracic surgery in chest trauma was traumatic diaphragmatic rupture caused mostly by penetrating thoracic injury. Thoracotomy was the major emergency thoracic surgical approach performed.