Massive Hemothorax Research Articles

Damage control surgery in lung trauma.

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively. Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management.

Delayed onset acute massive haemothorax after traumatic rib fractures-A Case Report

Rib fractures are common injuries that frequently necessitate intensive care admission for pain management, respiratory support, in addition to managing possible complications. The most common complications of rib fractures are pain, haemothorax, pneumothorax, pulmonary contusions and lacerations, vascular injuries, and intra-abdominal organ injury. After a high impact road traffic accident, a polytrauma 26-year-old Irish gentleman presented with right-sided posterior rib series fractures (from 8th to 12th rib), lung contusion, hepatic laceration, pelvic ring crush injury and urinary bladder disruption. Resuscitation and emergency management including suprapubic catheterisation and external pelvic fixation were performed successfully. Although complications of multiple rib fractures were excluded clinically and radiologically on admission, the patient developed acute massive haemothorax 5 days after the primary injury which has been managed appropriately. This incident raises the concern that haemothoraces and pneumothoraces can occur late after the original injury and high level of suspicion associated with follow-up chest x-ray images are essential in patients with rib fractures. Keywords: Polytrauma, Rib fracture, Haemothorax.

Spontaneous, Loculated, and Massive Hemothorax: An Uncommon Complication of Warfarin Therapy

Warfarin, a commonly used oral anticoagulant, is associated with several adverse drug reactions, principally bleeding. Of all hemorrhagic complications from warfarin therapy, thoracic hemorrhage accounts for only 3% and is usually related to trauma. Cases of spontaneous hemothorax secondary to anticoagulation therapy are rarely reported in the literature.

HEMOTHORAX FOLLOWING PENETRATING THORACIC INJURY (GUNSHOT WOUND) IN GERIATRIC PATIENT: A CASE REPORT AND EMERGENCY MANAGEMENT

Introduction: Penetrating chest trauma is highly lethal. Studies have reported up to 60% mortality depending on the mechanism of injury. While penetrating chest trauma is less common than blunt trauma, it can be more deadly. High-velocity gunshot injury resulting in penetrating thoracic trauma in geriatric patients poses a significant challenge for the traumatic surgeon. Hemothorax is usually a consequence of penetrating chest trauma. It can be caused by intercostal arterial bleeding, especially the posterior part. Initial treatment, including chest tube drainage insertion, is needed to avoid lung compression and to assess future treatment needed. Purpose: To report the patient survival from massive hemothorax caused by penetrating Thoracic injury caused by an air rifle, treated by chest tube insertion and posterolateral thoracotomy to take out the bullet several days after. Case Report: 70-year male patient came to the Emergency Room (ER) Adihusada Hospital Surabaya with a penetrating chest injury caused by an air rifle on the right side of the chest. The patient had chest pain, shortness of breath, and hypoxia. By inserting a chest tube, emergency management was done by a general surgeon due to the massive right hemothorax. An immediate chest tube insertion was needed to overcome the patient’s breathing problem to assess the future treatment needed. Chest X-ray and CT-Scan was done immediately after the patient’s hemodynamic were stable. Three days after hospitalizing, the Cardiothoracic and vascular surgeon performed posterolateral thoracotomy to take the bullet out of the chest. Conclusion: Seven days postoperatively, the patient was discharged from the hospital without any complications and stable hemodynamic. The patient went to the outpatient department for follow-up one week after.

Massive hemothorax in a pregnant patient with neurofibromatosis type 1

BackgroundReports of spontaneous hemothorax in patients with neurofibromatosis type 1 are scarce despite the severe complication. We herein present the first case of hemothorax in a neurofibromatosis type 1 patient during pregnancy and discuss the difficulty associated with its diagnosis and treatment.Case presentationA 39-year-old female at 34 weeks gestation presented with sudden left back pain and dyspnea. Chest radiography revealed massive left pleural effusion. Computed tomography showed bleeding from the intercostal artery. Although the patient appeared hemodynamically stable, the fetus was in a critical condition. Emergency caesarean section was performed within 1 hour. Subsequently, we performed endovascular coil embolization of the intercostal artery. While this intensive treatment saved the patient, her fetus could not be rescued.ConclusionsPatients with neurofibromatosis type 1 may develop massive hemothorax without gross lesions. In late pregnancy, sufficient infusion and quick hemostasis are essential and can be lifesaving.

Primary pulmonary Ewing\u2019s sarcoma: rare cause of massive hemothorax in a young girl-case report

BackgroundEwing’s sarcoma is a common malignant bone tumor in children and young adults. Rarely, extra-skeletal soft tissues and visceral organs can also be the site of origin of Ewing’s sarcoma. Primary pulmonary Ewing’s sarcoma is an extremely rare malignancy.Case presentationWe report an unusual case of primary pulmonary Ewing’s sarcoma in a 15-year-old girl who initially presented with massive hemothorax. By histopathology evaluation of surgical biopsy specimens, the diagnosis of extraosseous Ewing’s sarcoma was confirmed by both light microscopy and immunohistochemistry. Emergency, open surgery was performed by thoracic surgery at an early stage. After 3 cycles of chemotherapy, the patient was found to be stable at follow-up examination. No more hydrothorax or other symptoms.ConclusionsWe have described an extremely rare case of primary pulmonary Ewing’s sarcoma with massive hemothorax. The patient underwent surgical resection and postoperative chemotherapy, no sign of recurrence to date as an outcome.

Spontaneous Hemothorax in Infants: An Unusual Presentation

We report the case of a 40-day-old boy, who presented to hospital with tachypnea and sudden pallor. A pleural effusion in the left chest was observed on the chest X-ray. He was ventilated and thoracic drainage was performed because of degradation of his respiratory status. Computed Tomography as well as Magnetic Resonance Imaging supported strongly the diagnosis of mediastinal neuroblastoma. The extension assessment was negative. We opted for a conservative treatment by chemotherapy, and the courses proceeded favourably. After neoadjuvant chemotherapy, the residual mass was resected completely through a left thoracotomy. Histopathological examination established the final diagnosis of ganglioneuroblastoma. Thus, it is possible to avoid invasive treatment for massive hemothorax caused by neuroblastoma by initiating chemotherapy.

Extensive rib resection followed by thoracic wall reconstruction using polytetrafluoroethylene mesh and titanium plates for refractory intercostal artery bleeding induced by severe blunt thoracic injury: report of a case.

Massive hemothorax due to multiple rib fractures and intercostal artery (ICA) injuries is one of the most lethal forms of chest trauma. Urgent thoracotomy is required; however, suturing is sometimes difficult owing to the limited operative field in the thoracic cavity and because the transected ICA retracts between the surrounding intercostal muscles. We present a patient with refractory ICA bleeding induced by severe blunt thoracic injury successfully treated with extensive rib resection followed by thoracic wall reconstruction using GORE® DUALMESH® and titanium plates. A 66-year-old woman attempted suicide by diving into the path of a train. She incurred massive left hemothorax associated with multiple rib fractures and severe trauma to her extremities; both upper limbs and left leg at the thigh were nearly disconnected. Initially, she underwent urgent left anterolateral thoracotomy followed by partial lung resection and suture hemostasis of the thoracic wall. Subsequently, interventional radiology was performed for the ICA bleeding, and her extremities except her right leg were amputated. However, because hemothorax persisted, and because of the comminuted fractures, we removed the fifth to eighth ribs, and the ICA vascular sheath was ligated. Resecting multiple ribs caused deformities and lung herniations, although hemostasis was achieved. On the third postoperative day, thoracic reconstruction using Gore-Tex® Dual Mesh and titanium plates was performed. Although a small empyema occurred, it was controlled with antibiotics and drainage. Paradoxical respiration and atelectasis did not occur, and the patient was moved to the hospital for continued care in a lucid state.

A Case of Massive Hemothorax Leading to Obstructive Shock

Obstructive shock is one of the rarest types of shock. It is caused by the reduction of cardiac output despite normal intravascular volume or cardiac function. In this case report, we present a case of a seventy-four-year-old female, who was sent to our emergency department (ED) for evaluation of one week history of dyspnea and abnormal chest X-ray. Initial Contrast Tomography (CT) scan of the chest showed a large necrotic left upper lobe mass with multiple pulmonary nodules, small left-sided pleural effusion and mediastinal lymphadenopathy. Few days later, she developed worsening dyspnea and hypotension, requiring intubation and vasopressors for hemodynamic support. A repeat CT scan showed large left-sided pleural effusion with rightward mediastinal shift that required thoracostomy tube insertion to immediately improve the underlying obstructive shock.

Massive hemothorax following failed internal jugular vein access during an electrophysiological procedure: “Early detection – catastrophe averted”

We report an unusual case of massive hemothorax in a female patient undergoing electrophysiological (EP) procedure for drug-refractory supraventricular tachycardia. She underwent percutaneous intervention with a drug-eluting stent to the right coronary artery 6 months back and was on dual antiplatelet drugs. Timely detection and management of hemothorax prevented a major catastrophe in this patient. This case highlights the importance of keeping a strict vigil for possible occurrence of life-threatening bleeding complications during EP procedure in patients on multiple antiplatelet drug therapy.

Endovascular management of spontaneous inferior phrenic artery pseudoaneurysm presenting as massive hemothorax.

Endovascular management of spontaneous inferior phrenic artery pseudoaneurysm presenting as massive hemothorax.

THE STORY OF ONE PATIENT: MULTIPLE TRAUMA, ECMO, THE PATH TO LUNG TRANSPLANTATION AND ...

The mortality rate for multiple trauma in combination with severe chest trauma according to Abbreviated Injury Scale (AIS) > 3 is very high: 15.1% for all ages and 28.4% for people 65 years and older [7]. Severe contusion of the lungs can lead to massive hemothorax and severe tracheobronchial bleeding. If, for hemothorax, urgent surgery is performed based on chest drainage only, it is relatively difficult to find the source of tracheobronchial bleeding at an early stage of injury due to positive airway pressure ventilation. Due to lung contusion, a huge amount of tissue factor is released, which worsens coagulopathy and leads to increased bleeding. Worsening respiratory failure can also be caused by blood flow to the area of intact lungs from the area of the injured lungs. The incidence of acute respiratory distress syndrome in trauma patients ranges from 4.3 to 8.5%. In such cases, it is very difficult to maintain respiratory function only by standard ventilation control. Over the past two decades, a number of treatments have been developed that have improved the survival rate of patients with ARDS. Titration of lower tidal volumes and positive end-expiratory pressure (PEEP) significantly reduces mortality compared to traditional mechanical ventilation with high tidal volumes. In recent years, neuromuscular blocks and prone positioning have been introduced, demonstrating the mortality benefits of ARDS. Other supportive therapies are used, such as inhalation of prostacyclin, as well as alternative ventilation modes, such as bi-level ventilation or reduced airway pressure ventilation (APRV). Despite these advances in emergency therapies, some patients continue to deteriorate, and in such cases, veno-venous extracorporeal membrane oxygenation (IV-ECMO) becomes the best option as a last resort to save the lives of these patients.In this article, we presented a case of severe multiple trauma in a 35-year-old man with massive contusion of the lungs and continuing tracheobronchial bleeding, which led to the development of ARDS, destructive processes in the lungs and became the reason for the connection and long-term presence of the patient on VV-ECMO, due to the impossibility of providing with the help of mechanical ventilation gas exchange in the lungs.

Is massive hemothorax still an absolute indication for operation in blunt trauma?

BackgroundSurgery is usually suggested to treat massive haemothorax (MHT). The MHT criteria are based on penetrating trauma observations in military scenarios; the need for surgery in blunt trauma patients remains questionable. This study aimed to determine the characteristics of blunt trauma patients with MHT who required surgery. MethodsPatients who presented to the emergency department (ED) with traumatic haemothorax or pneumothorax, heart and lung injuries, and thoracic blood vessel injuries from Jan 1, 2014, to Dec 31, 2018, were reviewed. The inclusion criterion was a chest tube drainage amount that met the MHT criteria. Therapeutic operations were defined as those involving surgical haemostasis; otherwise, operations were considered non-therapeutic. The non-therapeutic operation group included the patients who received nonoperative management. The characteristics of the therapeutic and non-therapeutic operation groups were compared. ResultsForty-four patients were enroled in the study. Six patients received conservative treatment and were discharged uneventfully. Eleven patients underwent non-therapeutic operations. The patients with surgical bleeding had a high pulse rate (125.0 (111.0, 135.0) vs. 116.0 (84.0, 121.0) bpm, p = 0.013); low systolic blood pressure (SBP) after resuscitation (106.0 (84.0, 127.0) vs. 121.0 (116.0, 134.0) mmHg, p = 0.040); low pH (7.2 (7.2, 7.3) vs. 7.4 (7.3, 7.4), p = 0.002); and low bicarbonate (17.8 (14.6, 21.5) vs. 21.4 (17.0, 21.5) mEq/L, p = 0.038), low base excess (-9.1 (-13.4, -4.5) vs. -3.8 (-10.1, -0.7), p = 0.028), and high lactate (5.7 (3.3, 7.8) vs. 1.8 (1.7, 2.8) mmol/L, p = 0.002) levels. ConclusionConservative treatment could be performed selectively in patients with MHT. Lactate could be a predictor of the need for surgical intervention in blunt trauma patients with MHT.

Thoracic endometriosis syndrome in Nigeria: a single-centre experience.

Thoracic endometriosis syndrome (TES) is the presence of functional endometrial tissue in or around the lung. There seem to be differences in the clinical presentation of this condition among Nigerian patients. We aim to study the clinical presentation and management outcome of TES in our centre. This is an analysis of consecutive patients with TES treated over a 5-year period and followed up for 6 months to 5 years. Information collected included the gynaecological history, clinical presentation, causes of misdiagnosis, modalities of treatment and outcome. Twenty-three patients with TES aged between 24 and 45 years (median 32 years) were treated. Severe dysmenorrhoea was a prominent symptom in 91.3% of cases (median dysmenorrhoea score 8) and was uninfluenced by the marital status (P = 0.522). The patients usually presented with massive or recurrent haemothorax associated with massive ascites [16/23 (69.5%) of cases (P = 0.0006)]. The right side alone was involved in 21 cases and 1 patient had catamenial haemoptysis as a part of her symptoms, even though there was bronchial bleed at bronchoscopy in 6 patients. In 40%, tuberculosis was the misdiagnosis. Diagnosis was established histologically in 18/23 (78.3%) of the cases. Treatment was multimodal and multidisciplinary with notable macroscopic lesions in 77.8% of the patients that had surgery. TES is not an uncommon lesion. Presentation with massive haemothorax is usually associated with massive ascites. A large percentage of such have pleural and diaphragmatic lesions that require surgical treatment. The ascites may be refractory to treatment requiring repeated paracentesis.

Left-sided blunt diaphragmatic rupture with a massive hemothorax due to complete transection of the left renal artery

Left-sided blunt diaphragmatic rupture with a massive hemothorax due to complete transection of the left renal artery

Predictive Factors for Massive Transfusion in Trauma: A Novel Clinical Score from an Italian Trauma Center and German Trauma Registry.

Early management of critical bleeding and coagulopathy can improve patient survival. The aim of our study was to identify independent predictors of critical bleeding and to build a clinical score for early risk stratification. A prospective analysis was performed on a cohort of trauma patients with at least one hypotensive episode during pre-hospital (PH) care or in the Emergency Department (ED). Patients who received massive transfusion (MT+) (≥4 blood units during the first hour) were compared to those who did not (MT−). Hemodynamics, Glagow Coma Score (GCS), diagnostics and blood tests were evaluated. Using multivariate analysis, we created and validated a predictive score for MT+ patients. The predictive score was validated on a matched cohort of patients of the German Trauma Registry TR-DGU. One hundred thirty-nine patients were included. Independent predictors of MT+ included a prehospital (PH) GCS of 3, PH administration of tranexamic acid, hypotension and tachycardia upon admission, coagulopathy and injuries with significant bleeding such as limb amputation, hemoperitoneum, pelvic fracture, massive hemothorax. The derived predictive score revealed an area under the curve (AUC) of 0.854. Massive transfusion is essential to damage control resuscitation. Altered GCS, unstable hemodynamics, coagulopathy and bleeding injuries can allow early identification of patients at risk for critical hemorrhage.

PRIMARY MEDIASTINAL CHORIOCARCINOMA (PMC) IN A YOUNG WOMAN WITH HEMOPTYSIS AND A LUNG MASS

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary mediastinal choriocarcinoma (PMC) is an extra gonadal, non-gestational, angioinvasive rare germ cell neoplasm that mostly arises along the midline structures. PMC contains syncytiotrophoblastic cells which secrete human chorionic gonadotropin hormone (hCG). An elevated hCG is considered an important serologic tumor marker in the diagnosis of mediastinal germ cell tumor, in the absence of gestation and with no previous gynecologic malignancy. CASE PRESENTATION: A 39 year-old woman with no past medical history was admitted to the hospital with severe right sided chest pain associated with hemoptysis that started 2 weeks prior to admission. Physical exam revealed decreased breath sounds on the right hemithorax with dullness to percussion. Bloodwork was significant for β-HCG of 6,566 mlU/ml with negative alpha fetoprotein, and normal lactate dehydrogenase. A CT scan of the chest revealed a large necrotic solid mass with numerus enlarged vessels located in the anterior mediastinum (Figure 1). PET scan was negative for any metastatic lesions. Transvaginal ultrasound was negative for intrauterine or ectopic pregnancy. Transthoracic core biopsy showed poorly differentiated choriocarcinoma. Immunohistochemistry staining was positive for β-HCG, placental alkaline phosphatase, and pancytokeratin AE1/AE3 (Figure 2). The tumor was not amenable to surgical resection due to its large size and high vascularity. The patient was started on cisplatin and etoposide followed by etoposide, MTX, Act-D, cyclophosphamide, and vincristine (EMA-CO). After the first course of chemotherapy, the levels of β-HCG markedly decreased. DISCUSSION: PMC is a rare malignancy in both genders, more prevalent in men than in women. The natural process of PMC has been poorly understood. Possible theories include: (1) trophoblastic embolus related to a gestational event after a long period of latency; (2) metastases from a primary gonadal choriocarcinoma; (3) retained primordial germ cells that migrated during embryogenesis. An extensive workup is required to exclude other β-HCG-positive tumors from PMC, such as primary poorly differentiated non-small cell carcinoma of the lung, and gestational metastatic choriocarcinoma. Our patient was found to have a large highly vascular mass in the presence of elevated β-HCG, and absence of primary genital tumor. The histological features showed extensive areas of hemorrhage and necrosis and biphasic cellular population including cytotrophoblastic and syncytiotrophoblastic cells. In contrast to gestational choriocarcinoma, PMC is rapidly progressive and fatal in the great majority of cases with a dismal 5 years survival of less than 5%. CONCLUSIONS: Due to the rarity of PMC, currently there is no consensus regarding treatment guidelines. Thus, case reports such as this contribute to the scant literature to raise the profile of this rare and devastating disease. Reference #1: Ruan Z, Wang S, Wang Z, Jing Y. A rare case of bilateral massive hemothorax from spontaneous rupture of a primary mediastinal mixed germ cell tumor. Ann Thorac Surg. 2012;93:664–666 Reference #2: Bachmann J, Ernestus K, Werner T, et al. Detection of primary choriocarcinoma in the mediastinum by F-18 FDG positron emission tomography. Clin Nucl Med. 2007;32:663–665. Reference #3: Serno J, Zeppernick F, Jakel J, Primary pulmonary choriocarcinoma; cas report and the review of the literature, Gynecologic nad obstetric investigation, vol. 74, no. 2, pp. 171-176,2012 DISCLOSURES: No relevant relationships by Marwah Abduljabbar, source=Web Response No relevant relationships by Sara Mehrsefat, source=Web Response No relevant relationships by jorge otoya, source=Web Response No relevant relationships by Noman Subhani, source=Web Response no disclosure on file for Maria Wallis-Crespo

Massive hemothorax due to bleeding from thoracic spinal fractures: a case series and systematic review

BackgroundMassive hemothorax secondary to thoracic spinal fractures is rare, and its clinical characteristics, treatment, and prognosis are unknown. We present two cases of thoracic spinal fracture-induced massive hemothorax and a systematic review of previously reported cases.MethodsThis study included patients with traumatic hemothorax from thoracic spinal fractures at a Japanese tertiary care hospital. A systematic review of published cases was undertaken through searches in PubMed, EMBASE, and ICHUSHI from inception to October 13, 2019.ResultsCase 1: An 81-year-old man developed hemodynamic instability from a right hemothorax with multiple rib fractures following a pedestrian–vehicle accident; > 1500 mL blood was evacuated through the intercostal drain. Thoracotomy showed hemorrhage from a T8-burst fracture, and gauze packing was used for hemostasis. Case 2: A 64-year-old man with right hemothorax and hypotension after a fall from height had hemorrhage from a T7-burst fracture, detected on thoracotomy, which was sealed with bone wax. Hypotension recurred during transfer; re-thoracotomy showed bleeding from a T7 fracture, which was packed with bone wax and gauze for hemostasis. The systematic review identified 10 similar cases and analyzed 12 cases, including the abovementioned cases. Inferior part of thoracic spines was prone to injury and induced right-sided hemothorax. Most patients developed hemodynamic instability, and some sustained intra-transfer hemorrhage; direct compression (gauze packing, bone wax, and hemostatic agents) was the commonest hemostatic procedure. The mortality rate was 33.3%.ConclusionsHemothorax due to thoracic spinal fracture can be fatal. Thoracotomy with direct compression is necessary in hemodynamically unstable patients.

Too Big, Too Small or Just Right? Why the 28 French Chest Tube Is the Best Size

BackgroundTube thoracostomy is a commonly performed procedure in trauma patients. The optimal chest tube size is unknown. This study measures chest tube drainage in a controlled laboratory setting and compares measured flowrates to those predicted by the Hagen–Poiseuille equation. Materials and methodsA model of massive hemothorax was created, consisting of a basin containing synthetic blood substitute (aqueous Glycerin and Xanthan gum) and a standard pleur-evac setup at −20 cm H2O suction. Flow measurements were calculated by measuring the time to drain 2L of blood substitute from the basin. Chest tube sizes tested were 20F, 24F, 28F, 32F, and 36F. Thoracostomy opening was modeled using custom built device that represents two ribs, with the distance between varied 2 to 12 mm. Flowrate increases were compared against predicted increases according to the Hagen–Poiseuille equation. Percent of predicted increase was calculated, both incremental increase and using 20F tube benchmark. ResultsAll tubes were occluded at a 2 mm thoracostomy opening. At 3 mm, 32F and 36F were occluded while smaller tubes were patent. Tubes 28F and larger exhibited high speed and consistent flowrates, even after decreasing thoracostomy opening down to 7 mm, while flowrates rapidly decreased at opening smaller than 7 mm. Smaller 24F and 20F tubes exhibited highly variable flowrates through the system. Maximum flowrates were 21.7, 36.8, 49.6, 55.6, and 61.0 mL/s for 20F–36F tubes, respectively. The incremental increase in flow ratio for increasing chest tube size was 1.69 (20F to 24F), 1.35 (24F to 28F), 1.12 (28F to 32F), and 1.10 (32F to 36F). ConclusionsThe 28F chest tube exhibited high and consistent velocity, while smaller tubes were slower and more variable. Larger tubes offered only slightly higher flowrates. The 28F is a good balance of reasonable size and high flowrate and is likely the optimal size for most clinical applications.

To be a surgeon may be life saving

In the first 24 h after multiple rib fractures, a life-threatening massive hemothorax is very rare but can cause death at home in cases who have been discharged. A 50-year-old male general surgeon, was admitted to the emergency unit after a motorcycle accident. Multiple rib fractures were diagnosed but no hemopneumothorax or hemodynamic instability were observed. After 24 h of observation, he was discharged. On the fifth day at home he was woken by symptoms of acute massive hemothorax. With the assistance of his wife he commenced intravenous fluid resuscitation to treat his own hemodynamic instability and transferred himself to his own hospital via ambulance where he subsequently underwent thoracotomy for arrest of haemorrhage. Late development of a massive hemopneumothorax after multiple rib fractures is rare, but may be a life-threatening risk. Such patients should be more closely followed up and informed about symptoms and treatment.