Thoracic Ultrasound for Detection of Pneumothorax Following Thoracostomy Tube Removal in Trauma Patients.

INTRODUCTION: Screening for pneumothorax (PTX) is standard practice after thoracostomy tube removal, with postpull CXR being the gold standard. However, studies have shown that point-of-care thoracic ultrasound (POCTUS) is effective at detecting PTX and may represent a viable alternative. This study aims to evaluate the safety and efficacy of POCTUS for evaluation of clinically significant postpull PTX compared with chest x-ray (CXR). METHODS: We performed a prospective, cohort study at a Level 1 trauma center between April and December 2022 comparing the ability of POCTUS to detect clinically significant postpull PTX compared with CXR. Patients with thoracostomy tube placed for PTX, hemothorax, or hemopneumothorax were included. Clinically insignificant PTX was defined as a small residual or apical PTX without associated respiratory symptoms or need for thoracostomy tube replacement while clinically significant PTX were moderate to large or associated with physiologic change. RESULTS: We included 82 patients, the most common etiology was blunt trauma (n = 57), and the indications for thoracostomy tube placement were: PTX (n = 38), hemothorax (n = 15), and hemopneumothorax (n = 14). One patient required thoracostomy tube replacement for recurrent PTX identified by both ultrasound and X-ray. Thoracic ultrasound had a sensitivity of 100%, specificity of 95%, positive predictive value of 60%, and negative predictive value of 100% for the detection of clinically significant postpull PTX. CONCLUSIONS: The use of POCTUS for the detection of clinically significant PTX after thoracostomy tube removal is a safe and effective alternative to standard CXR. This echoes similar studies and emphasizes the need for further investigation in a multicenter study.

[VATS in Thorax Trauma]. / Videoassistierte Thorakoskopie (VATS) beim Thoraxtrauma.

Since the early 1990s, video-assisted thoracoscopy (VATS) has been increasingly established for a variety of indications in the treatment of patients with thoracic trauma. During this time, one premise for the use of thoracoscopy has not changed. Its use is consistently recommended only for trauma patients with stable circulation and respiration. To define the indications of VATS for use in thoracic trauma, the Pulmonary Injury Group - as part of the Working Committee for Thoracic Trauma of the German Society for Thoracic Surgery (DGT) and the German Society for Trauma Surgery (DGU) - has developed treatment recommendations based on a current literature review (based on the PRISMA Checklist/here: MEDLINE via PubMed from 1993 to 2022). In the present study, after reviewing the available literature, the indications for VATS in the care of thoracic trauma were identified, in order to formulate clinical recommendations for the use of VATS in thoracic trauma. The analysis of 1679 references identified a total of 4 randomised controlled trials (RCTs), 4 clinical trials, and 5 meta-analyses or systematic reviews and 39 reviews, which do not allow a higher level of recommendation than consensual recommendations, due to the low evidence of the available literature. Over the past 30 years, stabilisation options in the care of trauma patients have improved significantly, allowing expansion of indications for the use of VATS. Moreover, the recommendation for more than 50 years to thoracotomise trauma patients in case of an initial blood loss ≥ 1500 ml via the inserted chest drainage or in case of continuous blood loss ≥ 250 ml/h over 4 h is now only relative with today's better stabilisation measures. For unstable/non-stabilisable patients with a thoracic injury requiring emergency treatment, thoracotomy remains the method of choice, while VATS is recommended for a wide range of indications in the diagnosis and treatment of stable patients with a penetrating or blunt thoracic trauma. The indications for VATS are persistent haemothorax, treatment of injuries and haemorrhages to the lung, diaphragm, thoracic wall and other organ injuries, and in the secondary phase, treatment of thoracic sequelae of injury (empyema, persistent pulmonary fistula, infected atelectasis, etc.).

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.

Thoracic endometriosis presenting as hemopneumothorax.

Thoracic endometriosis is very rare. Usually, the thorax is the most frequent affected site outside the pelvis. Common symptoms include chest pain, dyspnea, and hemoptysis. Common manifestations include pneumothorax, hemothorax, and pulmonary or pleural nodules. In addition, symptoms and manifestations can be "catamenial" happening a few days after menstruation onset. This disease can be debilitating, causing a significant impact on the quality of life of young women. We present a case of a young female who was referred to our hospital with recurrent right-sided pleural effusions and pneumothoraces. Pleural fluid drainage was consistent with hemothorax. Transvaginal ultrasound showed mild intraperitoneal fluid in the Cul-de-Sac. Due to concerns for thoracic endometriosis, video-assisted thoracoscopic surgery was performed confirming the diagnosis by pathology. Therapeutic pleurectomy with diaphragmatic repair and pleurodesis was performed. The patient was started on medroxyprogesterone acetate injections two weeks after with great clinical response.

Multifocal pleural capillary hemangioma: a rare cause of hemorrhagic pleural effusion-case report.

BACKGROUND: Capillary hemangioma can be found in many organs, but rarely in pleura. Previously, only localized pleural capillary hemangioma cases have been reported. Corticosteroids are the most commonly recommended drugs in capillary hemangioma. CASE PRESENTATION: Here, we present a case of a young woman with recurrent hemorrhagic pleural effusion. Despite repeatedly thoracentesis, the routine examinations, including chest computed tomography (CT) scan, pleural effusion biochemical test, and cytology all failed to make a definite diagnosis. Thus, single port video-assisted thoracoscopy (VATS) was then performed. Numerous nodules arising from the parietal pleura were found, and biopsies showed multifocal pleural capillary. However, recurrent pleural effusion was successfully managed by oral azathioprine, after failure of dexamethasone treatment. CONCLUSIONS: To our knowledge, this is the first case of a patient with recurrent hemorrhagic pleural effusion masquerading as malignant pleurisy, but in fact caused by multifocal pleural capillary hemangioma.

Primary pulmonary Ewing's sarcoma: rare cause of massive hemothorax in a young girl-case report.

BACKGROUND: Ewing'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 PRESENTATION: We 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. CONCLUSIONS: We 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.

[Treatment of a patient with acute thoracoabdominal aortic dissection complicated by haemothorax]. / Lechenie patsienta s ostroi dissektsiei torakoabdominal'nogo otdela aorty, oslozhnennoi gemotoraksom.

Total left-sided haemothorax is a rare and severe complication of acute DeBakey type III aortic dissection. The primary aim of treatment is immediate arrest of haemorrhage and stabilization of the haemodynamic status of the patient. Endovascular isolation of the ruptured thoracic portion of the aorta using a stent graft (TEVAR) has recently become the 'gold standard' in treatment of acute, rupture-complicated aortic dissections of this localization. Described in the article is a clinical case report concerning successful endovascular treatment of a seriously ill patient with dissection of the thoracoabdominal portion of the aorta, rupture and massive haemorrhage into the left pleural cavity. The patient underwent endoprosthetic repair of the descending aorta in the setting of a hybrid operating room under local anaesthesia, followed by drainage of the left pleural cavity. The postoperative period was uneventful with no complications. The patient was discharged in a satisfactory condition on day 10 after the emergency surgical intervention. An important advantage of TEVAR for aortic ruptures is a minimally invasive nature of the procedure, consisting in no need to perform either sternothoracotomy or to connect a heart-lung machine, thus decreasing surgical wound, reducing the risk of perioperative life-threatening haemorrhage, and contributing to early activation of the patient.

Anti-clogging mechanisms of a motion-activated chest tube patency maintenance system: Histology and high-speed camera assessment.

The motion-activated system (MAS) employs vibration to prevent intraluminal chest tube clogging. We evaluated the intraluminal clot formation inside chest tubes using high-speed camera imaging and postexplant histology analysis of thrombus. The chest tube clogging was tested (MAS vs. control) in acute hemothorax porcine models (n = 5). The whole tubes with blood clots were fixed with formalin-acetic acid solution and cut into cross-sections, proceeded for H&E-stained paraffin-embedded tissue sections (MAS sections, n = 11; control sections, n = 11), and analyzed. As a separate effort, a high-speed camera (FASTCAM Mini AX200, 100-mm Zeiss lens) was used to visualize the whole blood clogging pattern inside the chest tube cross-sectional view. Histology revealed a thin string-like fibrin deposition, which showed spiral eddy or aggregate within the blood clots in most sections of Group MAS, but not in those of the control group. Histology findings were compatible with high-speed camera views. The high-speed camera images showed a device-specific intraluminal blood "swirling" pattern. Our findings suggest that a continuous spiral flow in blood within the chest tube (MAS vs. static control) contributes to the formation of a spiral string-like fibrin network during consumption of coagulation factors. As a result, the spiral flow may prevent formation of thick band-like fibrin deposits sticking to the inner tube surface and causing tube clogging, and thus may positively affect chest tube patency and drainage.

An unusual cause of chest pain in a 33 year old male: neurofibromatosis.

Chest pain in low risk patients is a common ED presentation. Rarely, these patients can have life-threatening conditions requiring timely diagnosis and intervention. There are currently standardized protocols for diagnosing cardiac ischemia, pulmonary embolus, and aortic dissection in low risk patients. Even more rare entities such as esophageal perforation, hemo/pneumothorax, and cardiac tamponade must also be kept in mind. We present the case of chest pain in a 33 year old male reporting no significant past medical history who developed spontaneous massive hemothorax while being evaluated in the ED. Subsequent investigation revealed that the patient had neurofibromatosis; the etiology of aneurysmal rupture in neurofibromatosis is discussed.

Spontaneous bilateral haemothorax with haemopericardium secondary to rivaroxaban.

WHAT IS KNOWN AND OBJECTIVE: Although the risk of major bleeding with non-vitamin K antagonist oral anticoagulant (NOAC) is low, life-threatening bleeding can occur. CASE SUMMARY: We report a case of an 81-year-old female with deep vein thrombosis who developed bilateral spontaneous haemothorax and haemopericardium after rivaroxaban therapy. Diagnostic thoracentesis revealed a grossly bloody pleural effusion. She was treated with factor eight inhibitor bypassing agent, but the result was not satisfactory. WHAT IS NEW AND CONCLUSION: To our knowledge, this is the first case report of a concomitant presentation of spontaneous bilateral haemothorax and haemopericardium due to rivaroxaban use. This case highlights the potential risk of major haemorrhagic complication of NOAC, which could be life-threatening and require emergent reversal.

Spontaneous pneumothorax and hemothorax frequently precede the arterial and intestinal complications of vascular Ehlers-Danlos syndrome.

Vascular Ehlers-Danlos syndrome (vEDS) is a connective tissue disorder due to defective type III collagen production and is associated with arterial rupture, spontaneous intestinal perforation, and gravid uterine rupture. Spontaneous pneumothorax and/or hemothorax (P/HTX) also occurs in vEDS patients. The temporal relation of pulmonary manifestations to arterial and intestinal complications in vEDS has not been well described. This was investigated in a multi-institutional retrospective case series of vEDS patients with confirmatory testing for COL3A1 mutation between 2000 and 2012. Data abstracted included demographics, family histories, presentation, and management of associated complications. Ninety-six cases (39% males, mean age 38.6 ± 15.5 years, range 8-79) had confirmatory testing for vEDS. P/HTX was documented in 17 (17.7%) cases. Most P/HTX preceded the diagnosis of vEDS (81%). Diagnosis of vEDS was made after arterial or intestinal complications at a mean of 7 years (range 0-26) post the initial P/HTX. In conclusion, spontaneous P/HTX is an early manifestation of vEDS frequently preceding an arterial complication or intestinal perforation. Thus, a spontaneous P/HTX in a young patient should trigger a differential diagnosis that includes vEDS. This should lead to an investigation of other vEDS features and subsequent genetic testing if vEDS features are present.

Case series of haemothorax secondary to avulsed bullae vessel.

Haemothorax refer to the bleeding in the pleural space. It is commonly due to iatrogenic, blunt or penetrating chest trauma. Non-traumatic haemothorax is a rare entity that can potentially lead to life threatening complications. The initial management of both traumatic and non-traumatic haemothorax includes resuscitation and stabilisation of the patient. We would like to present two cases of non-traumatic haemothorax secondary to an avulsed bullae vessel.

Spontaneous massive haemothorax in the peri-partum period of an undiagnosed neurofibromatosis type 1 patient - A surgical perspective.

Acute massive haemothorax is a life-threatening situation, which is often associated with a preceding trauma. However, spontaneous haemothorax is a rare occurrence, especially in pregnancy. Spontaneous haemothorax in the immediate post-partum period secondary to a ruptured intercostal AVM is extremely rare more so in the background of an undiagnosed neurofibromatosis. This is a report of a young lady presenting with pleuritis and breathlessness after the delivery of her 1st child. Her management is discussed.

An insidious and deadly complication of mechanical chest compressions in a patient on anticoagulation and the subtle echocardiographic findings that enabled timely diagnosis.

Good-quality chest compressions improve outcomes in cardiac arrest. While manual chest compressions are suboptimal in this regard, the LUCAS device has been shown to improve the effectiveness of chest compressions during cardiopulmonary resuscitation (CPR). The complication rate associated with mechanical CPR, however, has not been adequately studied. Limited evidence suggests no difference in internal injury between manual and mechanical CPR. We report the case of a patient on anticoagulation who developed a mediastinal hematoma post mechanical CPR and on whom subtle findings on initial echocardiography could have alerted the clinician to this complication early during the clinical course. This case further suggests that there may be special populations of patients in whom we may need to be more vigilant in the use of mechanical CPR.

[Hemothorax - a conservative approach in a patient with multiple comorbidities]. / Hemotórax ­ uma abordagem conservadora em doente com múltiplas comorbilidades.

The authors present the case of an elderly woman with multiple comorbidities hospitalized with the diagnosis of community- acquired pneumonia with pleural effusion. However, there was a history of fall with chest trauma 1 week before, coinciding with the onset of symptoms. The patient had a massive hemothorax that could not be drained. There was a progressive worsening of the patient clinical status with sustained fever and arising of inflammatory parameters, despite broad-spectrum antibiotic therapy and antipyretics. The case was discussed in a multidisciplinary team, and the possibility of surgical intervention was rejected. As life-saving therapy, it was decided to perform fibrinolysis with tissue plasminogen activator, through the thoracic drain, which occurred successfully and without complications. The hemothorax was drained completely allowing recovery of the patient.

Os autores apresentam o caso de uma mulher idosa, com múltiplas comorbilidades, internada com o diagnostico de pneumonia adquirida na comunidade com derrame pleural. No entanto, após nova história clínica constatou-se haver antecedentes de queda com traumatismo torácico 1 semana antes, coincidente com o início dos sintomas, sendo o derrame pleural um volumoso hemotórax que não foi possível drenar. Observou-se um agravamento progressivo do quadro clínico da doente com febre mantida e agravamento dos parâmetros inflamatórios, apesar da antibioterapia de largo espectro e terapêutica antipirética fixa. O caso foi discutido em equipa multidisciplinar, tendo sido rejeitada a hipótese de intervenção cirúrgica. Como terapêutica de life-saving, optou-se por realizar fibrinólise com fator ativador do plasminogénio tecidual, através do dreno torácico, o que ocorreu com sucesso e sem complicações. O hemotórax foi drenado na totalidade permitindo a recuperação da doente.

[Spontaneous haemothorax - thoracic surgeon and intervention radiologist successful cooperation]. / Spontán haemothorax ­ mellkassebész és intervenciós radiológus sikeres együttmuködése.

The definition of spontaneous haemothorax is accumulation of blood within the pleural space without trauma or iatrogenic causes. A case of a 17-year-old male patient with a history of multiple abnormal arterial fistulas between systemic circulation and pulmonary circulation as a cause of bleeding is presented. An overview of the causes, the clinical features of haemothorax and the interventional radiological methods that can solve some causes of haemothorax are presented in connection of our case report.

Giant Cell Tumor of the Ribs and Aneurysmal Bone Cyst Presenting With Hemothorax in a Child.

Giant cell tumor (GCT) is one of the most common tumors of bone and is the most common precursor of aneurysmal bone cysts (ABC). The clinical behavior of concurrent GCT and ABC can be very aggressive in children. GCT of the ribs, with or without ABC, is rarely seen in children. We report a case of an 8-year-old girl with GCT and associated ABC of the ribs who presented with sudden onset of chest pain and breathlessness due to a hemothorax. The patient was successfully treated by surgical resections and arterial embolization. She has remained well for 4 years after the initial surgery.

[Management of Thoracic Trauma]. / Thoraxtrauma: Diagnostik und Therapie.

Patients with a thoracic trauma are commonly treated by large bore chest tube thoracostomy and appropriate analgesia. The initial treatment is determined by the assessment of the emergency doctor and/or trauma surgeon. Severe intrathoracic lesions in polytrauma patients are rare. However, such injuries may be acutely life-threating. After primary stabilisation of the patients, imaging studies should be performed to assess the extent of the injuries and determine the treatment of choice. Assessment of such injuries should always be performed in a multidisciplinary team of anaesthesiologists, general surgeons, trauma surgeons and thoracic surgeons. For this reason, patients with thoracic traumas should always be treated in specialised centers. This approach reduces overall mortality and shortens the length of hospital stay.

Blunt chest trauma : clinical difficulties and limitations of radiological examinations.

Blunt chest trauma remains a public health problem due to the severity of caused injuries, diagnostic difficulties and therapeutic orientation. There is no correlation between the parietal lesions and endothoracic abnormalities. Instead radiological examinations are far from accurate. Through a study of 72 cases of closed chest trauma and a literature review we propose to identify risk factors of endothoracic lesions, to clarify the role of radiological examinations in the exploration of these injuries and propose a decisional algorithm.