Late video-assisted thoracoscopic surgery versus thoracostomy tube reinsertion for retained hemothorax after penetrating trauma, a prospective randomized control study.

BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.

Risk factors for delayed hemothorax in patients with rib fracture in the emergency department.

OBJECTIVES: Although rib fractures are a risk factor, not all rib fracture patients will develop delayed hemothorax. This study aimed to evaluate risk factors which can identify rib fracture patients in the emergency department who may develop delayed hemothorax. METHODS: Adult patients seen in the emergency room between January 2016 and February 2021 with rib fractures caused by blunt chest trauma were included in this retrospective observational study. Patients who underwent chest tube insertion within 2 days and those without follow-up chest radiographs within 2-30 days were excluded. We used a stepwise backward-elimination multivariable logistic regression model for analysis. RESULTS: A total of 202 patients were included in this study. The number of total (P < 0.001), lateral (P = 0.019), and displaced (P < 0.001) rib fractures were significantly associated with delayed hemothorax. Lung contusions (P = 0.002), and initial minimal hemothorax (P < 0.001) and pneumothorax (P < 0.001) were more frequently associated with delayed hemothorax. Age (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.00-1.06, P = 0.022), mechanical ventilator use (aOR 9.67, 95% CI 1.01-92.75, P = 0.049), initial hemothorax (aOR 2.21, 95% CI 1.05-4.65, P = 0.037) and pneumothorax (aOR 2.99, 95% CI 1.36-6.54, P = 0.006), and displaced rib fractures (aOR 3.51, 95% CI 1.64-7.53, P = 0.001) were independently associated with delayed hemothorax. CONCLUSIONS: Age, mechanical ventilation, initial hemo- or pneumothorax, and displaced rib fractures were risk factors for delayed hemothorax. Patients with these risk factors, and especially those with ≥2 displaced rib fractures, require close chest radiography follow-up of 2-30 days after the initial trauma.

Delayed hemothorax after anterior vertebral body tethering in adolescent idiopathic scoliosis: a case report.

PURPOSE: The aim of this case report is to report that delayed hemothorax is possible after anterior vertebral body tethering (aVBT) and to illustrate the course of treatment. METHODS: We present a 15-year-old boy with adolescent idiopathic scoliosis who underwent an anterior thoracoscopic assisted vertebral body tethering who developed a massive right-sided hemothorax 12 days post-operatively. A chest tube was placed to drain the hemothorax and later required embolectomy with tissue plasminogen activator (TPA) to drain the retained hemothorax. RESULTS: At 1 month follow up post discharge the patient was asymptomatic, and radiograph did not demonstrate evidence of residual hemothorax and scoliosis. We have followed this patient for 5 years postoperative and he continues to do well clinically and radiographically. CONCLUSIONS: Pulmonary complications are a known drawback of anterior thoracoscopic spinal instrumentation. Delayed hemothorax is possible after aVBT. In the case of a retained hemothorax, chest tube treatment with TPA is a safe and effective method of embolectomy.

Bupivacaine pleural effusion mimicking a hemothorax after a thoracoscopic microdiscectomy with epidural anesthesia.

PURPOSE: Post-operative pain after video-assisted thoracoscopic surgery is often treated using thoracic epidural analgesics or thoracic paravertebral analgesics. This article describes a case where a thoracic disc herniation is treated with a thoracoscopic microdiscectomy with post-operative thoracic epidural analgesics. The patient developed a bupivacaine pleural effusion which mimicked a hemothorax on computed tomography (CT). METHODS: The presence of bupivacaine in the pleural effusion was confirmed using a high performance liquid chromatography method. RESULTS: The patient underwent a re-exploration to relieve the pleural effusion. The patient showed a long-term recovery similar to what can be expected from an uncomplicated thoracoscopic microdiscectomy. CONCLUSION: A pleural effusion may occur when thoracic epidural analgesics are used in patents with a corridor between the pleural cavity and epidural space.

Intrapleural Fibrinolytic Interventions for Retained Hemothoraces in Rabbits.

Bleeding within the pleural space may result in persistent clot formation called retained hemothorax (RH). RH is prone to organization, which compromises effective drainage, leading to lung restriction and dyspnea. Intrapleural fibrinolytic therapy is used to clear the persistent organizing clot in lieu of surgery, but fibrinolysin selection, delivery strategies, and dosing have yet to be identified. We used a recently established rabbit model of RH to test whether intrapleural delivery of single-chain urokinase (scuPA) can most effectively clear RH. scuPA, or single-chain tissue plasminogen activator (sctPA), was delivered via thoracostomy tube on day 7 as either one or two doses 8 h apart. Pleural clot dissolution was assessed using transthoracic ultrasonography, chest computed tomography, two-dimensional and clot displacement measurements, and gross analysis. Two doses of scuPA (1 mg/kg) were more effective than a bolus dose of 2 mg/kg in resolving RH and facilitating drainage of pleural fluids (PF). Red blood cell counts in the PF of scuPA, or sctPA-treated rabbits were comparable, and no gross intrapleural hemorrhage was observed. Both fibrinolysins were equally effective in clearing clots and promoting pleural drainage. Biomarkers of inflammation and organization were likewise comparable in PF from both groups. The findings suggest that single-agent therapy may be effective in clearing RH; however, the clinical advantage of intrapleural scuPA remains to be established by future clinical trials.

Delayed Arterial Bleed After Pulmonary Lobectomy.

BACKGROUND: Postlobectomy hemorrhage is rare. The majority of the bleeding happens early after surgery, with the median time to reoperation being 17 hours. CASE REPORT: A 64-year-old man with a lung nodule underwent video-assisted thoracic surgery right upper lobectomy 3 weeks prior and presented to the Emergency Department (ED) with acute-onset chest pain and shortness of breath in the setting of delayed hemothorax from acute intercostal artery bleeding. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The vast majority of the patients presenting to the ED with a hemothorax have a known history of trauma. It is important for emergency physicians to consider and recognize hemothorax in nontraumatic patients, especially those who underwent recent lung surgeries. Delayed postoperative hemorrhage is rare but possible, and can be life threatening.

Risk factors and outcomes in pediatric blunt cardiac injuries.

PURPOSE: Unlike adults, less is known of the etiology and risk factors for blunt cardiac injury (BCI) in children. Identifying risk factors for BCI in pediatric patients will allow for more specific screening practices following blunt trauma. METHODS: A retrospective review was performed using the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019. All patients ≤ 16 years injured following blunt trauma were included. Demographics, mechanism, associated injuries, injury severity, and outcomes were collected. Univariate and multivariate regression was used to determine specific risk factors for BCI. RESULTS: Of 266,045 pediatric patients included in the analysis, the incidence of BCI was less than 0.2%. The all-cause mortality seen in patients with BCI was 26%. Motor-vehicle collisions (MVCs) were the most common mechanism, although no association with seatbelt use was seen in adolescents (p = 0.158). The strongest independent risk factors for BCI were pulmonary contusions (OR 15.4, p < 0.001) and hemothorax (OR 8.9, p < 0.001). CONCLUSIONS: Following trauma, the presence of pulmonary contusions or hemothorax should trigger additional screening investigations specific for BCI in pediatric patients.

A Novel Rabbit Model of Retained Hemothorax with Pleural Organization.

Retained hemothorax (RH) is a commonly encountered and potentially severe complication of intrapleural bleeding that can organize with lung restriction. Early surgical intervention and intrapleural fibrinolytic therapy have been advocated. However, the lack of a reliable, cost-effective model amenable to interventional testing has hampered our understanding of the role of pharmacological interventions in RH management. Here, we report the development of a new RH model in rabbits. RH was induced by sequential administration of up to three doses of recalcified citrated homologous rabbit donor blood plus thrombin via a chest tube. RH at 4, 7, and 10 days post-induction (RH4, RH7, and RH10, respectively) was characterized by clot retention, intrapleural organization, and increased pleural rind, similar to that of clinical RH. Clinical imaging techniques such as ultrasonography and computed tomography (CT) revealed the dynamic formation and resorption of intrapleural clots over time and the resulting lung restriction. RH7 and RH10 were evaluated in young (3 mo) animals of both sexes. The RH7 recapitulated the most clinically relevant RH attributes; therefore, we used this model further to evaluate the effect of age on RH development. Sanguineous pleural fluids (PFs) in the model were generally small and variably detected among different models. The rabbit model PFs exhibited a proinflammatory response reminiscent of human hemothorax PFs. Overall, RH7 results in the consistent formation of durable intrapleural clots, pleural adhesions, pleural thickening, and lung restriction. Protracted chest tube placement over 7 d was achieved, enabling direct intrapleural access for sampling and treatment. The model, particularly RH7, is amenable to testing new intrapleural pharmacologic interventions, including iterations of currently used empirically dosed agents or new candidates designed to safely and more effectively clear RH.

Factors Associated with Successful Video-Assisted Thoracoscopic Surgery and Thoracotomy in the Management of Traumatic Hemothorax.

BACKGROUND: Few studies have identified factors associated with successful VATS or thoracotomy as the initial operative strategy among patients with traumatic hemothorax. MATERIAL AND METHODS: We performed an exploratory analysis using the 2008 to 2017 TQP database. We identified all patients aged 18 to 89 years with traumatic hemothorax who were treated with tube thoracostomy alone in the first 24-hours of admission, followed by VATS or thoracotomy. Logistic regression was used to identify factors associated with successful VATS (no conversion or reoperation) or thoracotomy (no reoperation) as the initial operative strategy. RESULTS: Among 2052 patients managed with initial VATS after chest tube drainage, 1710 (83%) were successful, while 263 (13%) were converted to thoracotomy and 79 (4%) required reoperation. On multivariable analysis, poor GCS (OR = 0.96 [95% CI = 0.94-0.99]), major injury (OR = 0.69 [95% CI = 0.53-0.90]), and diaphragmatic injury (OR = 0.42 [95% CI = 0.30-0.60]) were associated with lower odds of successful VATS, while rib fractures (OR=1.29 [95% CI=1.01-1.66]) were associated with higher odds of success of the initial operative plan. Among 3486 patients initially managed with thoracotomy after drainage with tube thoracostomy, 3118 (89.4%) were successful, while 11% (n = 368) required reoperation. Multivariable analysis revealed that major injury (OR = 0.68 [95% CI = 0.50-0.92]), blunt mechanism (OR = 0.63 [95% CI = 0.50-0.78]), and diaphragmatic injury (OR = 0.67, 95% CI = 0.53-0.84]) were associated with lower odds of successful thoracotomy as the initial operative plan. CONCLUSIONS: More severe injuries and diaphragmatic injuries have lower odds of successful of VATS or thoracotomy as the initial operative management strategy among patients with traumatic hemothorax. Rib fractures may be associated with higher odds of success of VATS as the initial management strategy.

Factors Associated With Successful Video-Assisted Thoracoscopic Surgery for Traumatic Hemothorax in Children: A Cross-Sectional Study.

INTRODUCTION: Due to the rarity of traumatic hemothorax in children, no studies have evaluated factors associated with successful video-assisted thoracoscopic surgery (VATS) as definitive management. METHODS: We conducted an exploratory cross-sectional analysis of pediatric patients in the Trauma Quality Programs database from 2008 to 2017 with traumatic hemothorax managed with primary VATS. Those with early resuscitative thoracotomy for cardiac arrest were excluded. We stratified patients by blunt or penetrating mechanism and estimated absolute differences (ADs) and 95% confidence intervals (CIs) to identify factors associated with successful VATS without conversion to thoracotomy or reoperation. RESULTS: A total of 293 patients were eligible. Among 184 penetrating injuries, 150 (82%) underwent successful VATS, 6 (3%) required reoperation, and 28 (15%) converted to thoracotomy. Diaphragmatic injuries (AD = -28, 95% CI = -46 to -10) and rib fractures (AD = 12, 95% CI = 1 to 23) had the strongest negative and positive associations (respectively) with successful VATS. There were 109 blunt injuries: 86 (79%) underwent successful VATS, 6 (6%) required reoperation, and 17 (16%) converted to thoracotomy. Moderate or severe head injury (AD = -15, 95% CI = -32 to 2), injury severity score >15 (AD = -19, 95% CI = -33 to -5), and the presence of diaphragmatic injury (AD = -38, 95% CI = -71 to -4) had the strongest negative associations with successful VATS. CONCLUSIONS: Some children with traumatic hemothorax can be successfully managed with VATS. For penetrating mechanism, diaphragmatic injuries were associated with less success, while rib fractures were associated with more success. For blunt mechanism, diaphragmatic injuries, injury severity score >15, or moderate or severe head injury were associated with less success.

The Volume of Thoracic Irrigation Is Associated With Length of Stay in Patients With Traumatic Hemothorax.

INTRODUCTION: Irrigation of the thoracic cavity at tube thoracostomy (TT) placement may decrease the rate of a retained hemothorax (RHTX); however, other resource utilization outcomes have not yet been quantified. This study evaluated the association of thoracic irrigation during TT with the length of stay and outcomes in patients with traumatic hemothorax (HTX). METHODS: A retrospective chart review was performed of adult patients receiving a TT for HTX at a single, urban Level 1 Trauma Center from January 2019 to December 2020. Those who underwent irrigation during TT at the discretion of the trauma surgeon were compared to a control of standard TT without irrigation. Death within 30 d, as well as TTs, placed at outside hospitals, during traumatic arrest or thoracic procedures, and for isolated pneumothoraces were excluded. The primary outcome was the length of stay as hospital-free, ICU-free, and ventilator-free days (30-day benchmark). Subgroup analysis by irrigation volume was conducted using one-way ANOVA testing with P < 0.05 considered statistically significant. RESULTS: Eighty-two (41.4%) of 198 patients underwent irrigation during TT placement. Secondary interventions, thoracic infections, and TT duration were not statistically different in the irrigated cohort. Hospital-free and ICU-free days were higher in the irrigated patients than in the controls. Groups irrigated with ≥1000 mL had significant more hospital-free days (P = 0.007) than those receiving less than 1000 mL. CONCLUSIONS: Patients with traumatic HTX who underwent thoracic irrigation at the time of TT placement had decreased hospital and ICU days compared to standard TT placement alone. Specifically, our study demonstrated that patients irrigated with a volume of at least 1000 mL had greater hospital-free days compared to those irrigated with less than 1000 mL.

Predictors of Readmission Following Treatment for Traumatic Hemothorax.

INTRODUCTION: Retained-hemothorax after trauma can be associated with prolonged hospitalization, empyema, pneumonia, readmission, and the need for additional intervention. The purpose of this study is to reduce patient morbidity associated with retained-hemothorax by defining readmission rates and identifying predictors of readmission after traumatic hemothorax. METHODS: The Nationwide Readmission Database for 2017 was queried for patients with an index admission for traumatic hemothorax during the first 9 mo of the year. Deaths during the index admission were excluded. Data collected includes demographics, injury mechanism, outcomes and interventions including chest tube, video-assisted thoracoscopic surgery, and thoracotomy. Chest-related readmissions (CRR) were defined as hemothorax, pleural effusion, pyothorax, and lung abscess. Univariate and multivariate analysis were used to identify predictors of readmission. RESULTS: There were 13,903 patients admitted during the study period with a mean age of 53 ± 21, 75.2% were admitted after blunt versus 18.3% penetrating injury. The overall 90-day readmission rate was 20.8% (n = 2896). The 90-day CRR rate was 5.7% (n = 794), with 80.5% of these occurring within 30 d. Of all CRR, 62.3% (n = 495) required an intervention (chest tube 72.7%, Thoracotomy 26.9%, video-assisted thoracoscopic surgery 0.4%). Mortality for CRR was 6.2%. Predictors for CRR were age >50, pyothorax or pleural effusion during the index admission and discharge to another healthcare facility or skilled nursing facility. CONCLUSIONS: Majority of CRR after traumatic hemothorax occur within 30 d of discharge and frequently require invasive intervention. These findings can be used to improve post discharge follow-up and monitoring.

Retrospective Evaluation of Intrapleural Tissue Plasminogen Activator With or Without Dornase Alfa for the Treatment of Traumatic Retained Hemothorax: A 6-Year Experience.

BACKGROUND: Intrapleural fibrinolytic instillation is second-line treatment for retained hemothorax. Dornase alfa (DNase) has demonstrated efficacy in parapneumonic effusion, but the lack of deoxyribonucleoproteins limits direct extrapolation to traumatic retained hemothorax treatment. OBJECTIVE: This study evaluated the effectiveness of intrapleural tissue plasminogen activator (tPA) with and without DNase in the treatment of retained traumatic hemothorax. METHODS: This retrospective cohort study included patients aged 16 years and older admitted to a level 1 trauma center from January 2013 through July 2019 with retained hemothorax and one or more intrapleural tPA instillations. Exclusion criteria were tPA for other indications or concomitant empyema. The primary endpoint was treatment failure defined as the need for operative intervention. RESULTS: Fifty patients were included (tPA alone: 28; tPA with DNase: 22). Baseline characteristics were similar between groups, including time to diagnosis (6.5 [interquartile range (IQR), 4-15.5] days vs 6 [IQR, 6.3-10.8] days, P = 0.52). Median tPA dose per treatment (6 [IQR, 6-6.4] mg vs 10 [IQR, 8.4-10] mg, P < 0.001) and cumulative tPA (18 [IQR, 6.5-24] mg vs 30 [IQR, 29.5-40], P < 0.001) dose were significantly lower in the tPA alone group. Treatment failure was similar between groups. Chest tube output, retained hemothorax reduction, and bleeding incidences were similar between groups. Multivariate logistic regression demonstrated no significant risk factors for treatment failure. CONCLUSIONS AND RELEVANCE: Dornase alfa added to tPA may not reduce the need for operation to treat retained hemothorax. Further studies should be directed at optimal tPA dose determination and economic impact of inappropriate DNase use.

The role of routine chest radiography after implantable venous access port catheter insertion under the guide of ultrasonography and fluoroscopy.

BACKGROUND: The objective of this study is the evaluation of routine chest radiography following the placement of Implantable venous access port catheter (IVAPC) central lines using combined ultrasound and fluoroscopic guidance by a vascular surgeon in the operating room. MATERIAL AND METHOD: A prospective study of 189 consecutive patients who underwent IVAPC central line insertion in the vascular surgery operating room from 2016 to 2019. Venipuncture was performed with an 18-gauge needle under the guidance of sonography in each case, and the access site was noted. The line position was confirmed by fluoroscopy following the procedure. Multiple tries for puncture and patients under 18 were excluded from our study. Routine radiography of chest was performed for all patients and pneumothorax, hemothorax, and catheter malposition were evaluated in each case. RESULTS: There were 2 cases of asymptomatic pneumothorax, no cases of hemothorax, and all catheter tip positions were optimal or acceptable. The annual cost of chest radiography was 33,000,000IRR, 220 h of hospital and staff time, and 1.1 mSv radiation. CONCLUSION: In conclusion, when imaging guidance is used for IVAPC insertion by an experienced surgeon in a high-volume center, performing post-procedure routine chest radiography shows little benefit.

Efficacy of extended focused assessment with sonography for trauma using a portable handheld device for detecting hemothorax in a low resource setting; a multicenter longitudinal study.

INTRODUCTION: Chest trauma is one of the most important and commonest injuries that require timely diagnosis, accounting for 25-50% of trauma related deaths globally. Although CT scan is the gold standard for detection of haemothorax, it is only useful in stable patients, and remains unavailable in most hospitals in low income countries. Where available, it is very expensive. Sonography has been reported to have high accuracy and sensitivity in trauma diagnosis but is rarely used in trauma patients in low income settings in part due to lack of the sonography machines and lack of expertise among trauma care providers. Chest X-ray is the most available investigation for chest injuries in low income countries. However it is not often safe to wheel seriously injured, unstable trauma patients to X-ray rooms. This study aimed at determining the efficacy of extended focused assessment with sonography for trauma (eFAST) in detection of haemothorax using thoracostomy findings as surrogate gold standard in a low resource setting. METHODS: This was an observational longitudinal study that enrolled 104 study participants with chest trauma. Informed consent was obtained from all participants. A questionnaire was administered and eFAST, chest X-ray and tube thoracotomy were done as indicated. Data were analysed using SPSS version 22. The sensitivity, specificity, predictive values, accuracy and area under the curve were determined using thoracostomy findings as the gold standard. Ethical approval for the study was obtained from the Research and Ethics Committee of Kampala International University Western Campus REC number KIU-2021-53. RESULTS: eFAST was found to be superior to chest X-ray with sensitivity of 96.1% versus 45.1% respectively. The accuracy was also higher for eFAST (96.4% versus 49.1%) but the specificity was the same at 100.0%. The area under the curve was higher for eFAST (0.980, P = 0.001 versus 0.725, P = 0.136). Combining eFAST and X-ray increased both sensitivity and accuracy. CONCLUSION: This study revealed that eFAST was more sensitive at detecting haemothorax among chest trauma patients compared to chest X-ray. All patients presenting with chest trauma should have bedside eFAST for diagnosis of haemothorax.

Porous diaphragm syndrome presenting as hemothorax secondary to hemoperitoneum after laparoscopic myomectomy: A case report and literature review.

Porous diaphragm syndrome includes all pleural cavity conditions, including pleural effusion, hemothorax, or pneumothorax, that occur secondary to peritoneal cavity disorders through defects in the diaphragm. In this report, we describe the first known case of porous diaphragm syndrome presenting as hemothorax after laparoscopic myomectomy. A 46-year-old nulliparous woman underwent laparoscopic myomectomy for multiple fibroids. Eight hours after surgery, the patient developed exertional dyspnea followed by hemoptysis. Radiological diagnosis revealed massive hemothorax in the right thoracic cavity. Thoracoscopic findings showed the presence of small fenestrae at the center of the right diaphragm, which were repaired thoracoscopically. Hence, quick postoperative diagnosis resulted in successful treatment. In this case, porous diaphragm syndrome is believed to be caused by retention of intraoperative bleed and saline from intra-abdominal lavage, in the abdominal cavity. Porous diaphragm syndrome is a potential life-threatening condition that gynecological surgeons should consider in this era of laparoscopic surgery.

A pilot study of deep learning-based CT volumetry for traumatic hemothorax.

PURPOSE: We employ nnU-Net, a state-of-the-art self-configuring deep learning-based semantic segmentation method for quantitative visualization of hemothorax (HTX) in trauma patients, and assess performance using a combination of overlap and volume-based metrics. The accuracy of hemothorax volumes for predicting a composite of hemorrhage-related outcomes - massive transfusion (MT) and in-hospital mortality (IHM) not related to traumatic brain injury - is assessed and compared to subjective expert consensus grading by an experienced chest and emergency radiologist. MATERIALS AND METHODS: The study included manually labeled admission chest CTs from 77 consecutive adult patients with non-negligible (≥ 50 mL) traumatic HTX between 2016 and 2018 from one trauma center. DL results of ensembled nnU-Net were determined from fivefold cross-validation and compared to individual 2D, 3D, and cascaded 3D nnU-Net results using the Dice similarity coefficient (DSC) and volume similarity index. Pearson's r, intraclass correlation coefficient (ICC), and mean bias were also determined for the best performing model. Manual and automated hemothorax volumes and subjective hemothorax volume grades were analyzed as predictors of MT and IHM using AUC comparison. Volume cut-offs yielding sensitivity or specificity ≥ 90% were determined from ROC analysis. RESULTS: Ensembled nnU-Net achieved a mean DSC of 0.75 (SD: ± 0.12), and mean volume similarity of 0.91 (SD: ± 0.10), Pearson r of 0.93, and ICC of 0.92. Mean overmeasurement bias was only 1.7 mL despite a range of manual HTX volumes from 35 to 1503 mL (median: 178 mL). AUC of automated volumes for the composite outcome was 0.74 (95%CI: 0.58-0.91), compared to 0.76 (95%CI: 0.58-0.93) for manual volumes, and 0.76 (95%CI: 0.62-0.90) for consensus expert grading (p = 0.93). Automated volume cut-offs of 77 mL and 334 mL predicted the outcome with 93% sensitivity and 90% specificity respectively. CONCLUSION: Automated HTX volumetry had high method validity, yielded interpretable visual results, and had similar performance for the hemorrhage-related outcomes assessed compared to manual volumes and expert consensus grading. The results suggest promising avenues for automated HTX volumetry in research and clinical care.

Massive intrathoracic haemorrhage as a complication of pulmonary parenchymal haemorrhage and anticoagulant treatment of lung embolization during COVID-19 - two case reports.

INTRODUCTION: The medical and social interest in the SARS-CoV-2 infection is currently high. This infection can, in severe cases, be accompanied by a series of complications, such as thromboembolic disease or pulmonary parenchymal haemorrhage. CASE REPORTS: The paper presents two rare cases of massive intrathoracic haemorrhage caused by pulmonary parenchymal haemorrhage and exacerbated by full anticoagulant treatment of thromboembolic disease. RESULTS: In both cases, the haemorrhage originated in the left lower lobe and was life threatening, requiring urgent anatomical lung resection - left lower lobectomy. CONCLUSIONS: The combinaion of anticoagulant therapy and thromboembolic events related to COVID-19 can cause, in rare cases, massive pulmonary haemorrhage. This rare complication proved lethal in one out of two of the cases described in this paper. An imminent and adequate reaction is necessary when the first signs of haemorrhage appear.

Vascular Ehlers-Danlos syndrome (vEDS): CT and histologic findings of pleural and lung parenchymal damage.

OBJECTIVES: To describe CT features of lung involvement in patients with vascular Ehlers-Danlos syndrome (vEDS), a rare genetic condition caused by pathogenic variants within the COL3A1 gene, characterized by recurrent arterial, digestive, and pulmonary events. MATERIAL AND METHODS: All consecutive vEDS patients referred to the national tertiary referral center for vEDS, between 2004 and 2016, were included. Chest CT scans obtained during the initial vascular work-up were reviewed retrospectively by two chest radiologists for lung involvement. Five surgical samples underwent histologic examination. RESULTS: Among 136 enrolled patients (83 women, 53 men; mean age 37 years) with molecularly confirmed vEDS, 24 (17.6%) had a history of respiratory events: 17 with pneumothorax, 4 with hemothorax, and 3 with hemoptysis that required thoracic surgery in 11. CT scans detected lung parenchymal abnormalities in 78 (57.3%) patients: emphysema (mostly centrilobular and paraseptal) in 44 (32.3%), comparable for smokers and non-smokers; clusters of calcified small pulmonary nodules in 9 (6.6%); and cavitated nodules in 4 (2.9%). Histologic examination of surgical samples found arterial abnormalities, emphysema with alveolar ruptures in 3, accompanied by diffuse hemorrhage and increased hemosiderin resorption. CONCLUSION: In vEDS patients, identification of lung parenchymal abnormalities is common on CT. The most frequently observed CT finding was emphysema suggesting alveolar wall rupture which might facilitate the diagnostic screening of the disease in asymptomatic carriers of a genetic COL3A1 gene mutation. The prognostic value and evolution of these parenchymal abnormalities remain to be evaluated. KEY POINTS: • Patients with vEDS can have lung parenchymal changes on top of or next to thoracal vascular abnormalities and that these changes can be present in asymptomatic cases. • The presence of these parenchymal changes is associated with a slightly higher incidence of respiratory events (although not statistically significant). • Identification of the described CT pattern by radiologists and chest physicians may facilitate diagnostic screening.

Tension Hemopneumothorax in the Setting of Mechanical CPR during Prehospital Cardiac Arrest.

INTRODUCTION: There are several complications associated with automated mechanical CPR (AM-CPR), including tension pneumothoraces. The incidence of these complications and the risk factors for their development remain poorly characterized. Tension hemopneumothorax is a previously unreported complication of AM-CPR. The authors present a case of a suspected tension hemopneumothorax that developed during the use of an automated mechanical CPR device. Case Description: A 67 year-old woman with a history of COPD and CABG was observed by an off-duty firefighter to be slumped behind the wheel of an ice cream truck that drifted off the road at a low rate of speed and was stopped by a wooden fence, resulting in only minor paint scratches. The patient was found to be in cardiac arrest with a shockable rhythm. No signs of trauma were noted, and equal bilateral breath sounds were present with BVM ventilation. After 13 minutes of manual CPR, fire department personnel applied their Defibtech LifeLine ARM mechanical CPR device to the patient. During resuscitation, the device had to be repositioned twice due to rightward piston migration off of the sternum. Seven minutes after AM-CPR application, the patient had absent right-sided breath sounds and ventilations were more difficult. Needle decompression was performed with an audible release of air. A chest tube was placed by an EMS physician and roughly 400 mL of blood were immediately returned. At the next 2-minute pulse check, ROSC was noted, and the patient was transported to the hospital. She had an ischemic EKG and elevated troponin. Chest CT showed emphysematous lungs, bilateral rib fractures, and a small right-sided pneumothorax. Despite aggressive measures, the patient's condition gradually worsened, and she died 48 hours after presentation. Discussion/Conclusion: Migration of AM-CPR device pistons may contribute to the development of iatrogenic injuries such as hemopneumothoraces. Patients with underlying lung disease may be at a higher risk of developing pneumothoraces or hemopneumothoraces during the course of AM-CPR. Awareness of these potential complications may aid first responders by improving vigilance of piston location and by providing quicker recognition of iatrogenic injuries that need immediate attention to improve the opportunity for ROSC.