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.

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.

Right ventricular lead perforation with iatrogenic injury to an intercostal artery causing haemothorax after pacemaker implant.

A woman in her 80s experienced a life-threatening complication of pacemaker implant consisting of subacute right ventricular lead perforation causing iatrogenic injury to an intercostal artery, resulting in a large haemothorax. A CT scan confirmed active bleeding from the fourth intercostal artery. The patient underwent cardiothoracic surgery via a median sternotomy approach, during which the source of the bleeding was sealed, a new epicardial lead was positioned, and the original lead was extracted. This case emphasises the potentially severe consequences of pacemaker lead perforation and secondary injury to adjacent structures. It underscores the importance of early recognition and timely intervention, preferably in a tertiary specialist unit equipped for cardiothoracic surgery and confirms the value of pacemaker interrogation and CT scans for diagnosis.

Thoracic Lavage for Traumatic Hemothorax.

This Surgical Innovation discusses thoracic lavage for traumatic hemothorax.

CT-based pleural effusion volume estimation formula demonstrates low accuracy and reproducibility for traumatic hemothorax.

PURPOSE: We aimed to evaluate the accuracy and reproducibility of the CT-based volume estimation formula V = d2 * h, where d and h represent the maximum depth and height of the effusion, for acute traumatic hemothorax. MATERIALS & METHODS: Prospectively identified patients with CT showing acute traumatic hemothorax were considered. Volumes were retrospectively estimated using d2 * h, then manually measured on axial images. Subgroup analysis was performed on borderline-sized hemothorax (200-400 mL). Measurements were repeated by three non-radiologists. Bland-Altman analysis was used to assess agreement between the two methods and agreement between raters for each method. RESULTS: A total of 46 patients (median age 34; 36 men) with hemothorax volume 23-1622 mL (median 191 mL, IQR 99-324 mL) were evaluated. Limits of agreement between estimates and measured volumes were -718 - +842 mL (± 202 mL). Borderline-sized hemothorax (n = 13) limits of agreement were -300 - +121 mL (± 114 mL). Of all hemothorax, 85 % (n = 39/46) were correctly stratified as over or under 300 mL, and of borderline-sized hemothorax, 54 % (n = 7/13). Inter-rater limits of agreement were -251 - +350, -694 - +1019, and -696 - +957 for the estimation formula, respectively, and -124 - +190, -97 - +111, and -96 - +46 for the measured volume. DISCUSSION: An estimation formula varies with actual hemothorax volume by hundreds of mL. There is low accuracy in stratifying hemothorax volumes close to 300 mL. Variability between raters was substantially higher with the estimation formula than with manual measurements.

Cough-induced sudden acute chest pain and massive left hemothorax soon after pacemaker implantation.

A 74-year-old man who recently undergone a definitive pacemaker implantation with an apical septal active lead fixation presented to the emergency department because of a new-onset acute chest pain that began soon after cough episodes. Pacemaker interrogation reported an increased bipolar pacing threshold (3.25 V at 1 ms). Contrast-enhanced chest CT scan and percutaneous angiography revealed the sequential perforation of the right ventricular apex and the left internal mammary artery by the ventricular pacemaker lead. Successful percutaneous embolization of the LIMA, blood transfusion and thoracentesis were then performed, and the patient subsequently underwent a percutaneous ventricular lead extraction followed by re-implantation, with an uneventful follow-up after 2 years. This unique case report highlights a potential rare complication of the active fixation of the ventricular lead at the apical interventricular septum and should lead the clinicians to keep in mind right ventricular perforation, even without cardiac tamponade, in patients presenting for cardio-pulmonary symptoms soon after pacemaker implantation.

Massive haemothorax and haemorrhagic shock due to cervical vascular injury caused by a seat belt.

A woman in her 50s was transported to our hospital after experiencing a road traffic crash that led to a massive haemothorax and haemorrhagic shock due to a cervical vascular injury caused by the seat belt. Contrast-enhanced CT of the chest showed extravascular leakage of the contrast medium from the vicinity of the right subclavicular area and fluid accumulation in the thoracic cavity. The patient was intubated, and a thoracic drainage catheter was placed. She underwent angiography and embolisation of the right costocervical trunk, right thyrocervical trunk and right suprascapular artery using a gelatine sponge and 25% N-butylcyanoacrylate-Lipiodol. She was extubated on the second day after stabilisation of the respiratory and circulatory status. In cases where the bleeding vessel is known and an emergency thoracotomy can serve as a backup, embolisation by interventional radiology should be considered the initial treatment approach.

Recurrence of pulmonary sarcomatoid carcinoma presenting as haemothorax: a case report.

Pulmonary sarcomatoid carcinoma (PSC) is a rare and highly invasive malignant tumour. It has similar clinical manifestations and imaging features to ordinary lung cancer. This current case report describes a 65-year-old male patient who had a mass in the apicoposterior segment of the left upper lobe with haemoptysis. Imaging studies revealed a central parenchymal mass surrounded by areas of ground-glass opacity, strongly indicating the presence of a pulmonary malignancy. Intraoperatively, the tumour was discovered to have invaded the chest wall and exhibited a significant propensity for bleeding. Consequently, a left upper lobe resection accompanied by extensive pleural debridement were performed. Subsequent postoperative histopathological examination confirmed the diagnosis of PSC. Unfortunately, 1 month after the surgery, the patient presented with left-sided haemothorax. Despite employing various haemostatic interventions, the patient eventually succumbed to haemorrhagic shock. This study provides a treatment strategy reference for patients with PSC presenting as haemothorax.

Child abuse with multiple sharp foreign bodies penetrating the chest wall causing hemothorax and cardiac tamponade in two separate occasions: Case report.

We present a case of repeated child abuse causing left-sided hemothorax and cardiac tamponade on two separate occasions. A 14-year-old cerebral palsy male presented with left-sided hemothorax and multiple metallic foreign bodies in the chest wall managed by small limited incision, removal of the foreign bodies and chest tube. One week later, he came to our emergency department (ER) with multiple chest wall foreign bodies and tamponade managed by median sternotomy, removal of the foreign bodies, one of them was in the LAD. He had a smooth postoperative course and the case is under investigation.

Efficacy and safety of transcatheter arterial embolization for hemodynamically unstable bleeding after percutaneous transthoracic needle biopsy.

PURPOSE: To evaluate the safety and efficacy of transcatheter arterial embolization (TAE) in controlling hemodynamically unstable bleeding following a percutaneous transthoracic needle biopsy (PTNB). METHODS: A total of seven patients (four men and three women; mean age, 62 ± 12 years) who received TAE for post-PTNB bleeding between May 2007 and March 2022 were included. The observed types of bleeding were hemothorax (n = 3), hemoptysis (n = 2), and a combination of both (n = 2). In patients with active bleeding, the technical success of TAE was defined as superselective embolization of the target artery with no active bleeding visible on post-TAE angiography. Clinical success was defined as sustained cessation of bleeding without hemodynamic instability, requirement of repeat TAE, or the need for post-TAE hemostatic surgery during the initial admission. The metrics analyzed included technical and clinical success rates, complications, and 30-day mortality. RESULTS: All seven patients achieved technical success, with a clinical success rate of 86% (6/7). Six patients were discharged alive, while one patient died of respiratory failure accompanied by hemothorax 19 days post-biopsy. The angiographic findings associated with bleeding were contrast media extravasation or pseudoaneurysm (n = 3) and vascular hypertrophy with tortuosity (n = 2). The implicated bleeding arteries included the intercostal artery (n = 2), bronchial artery (n = 2), and internal thoracic artery (n = 1). In two cases, no clear bleeding foci were identified; nonetheless, prophylactic embolization was performed on the right intercostal artery (n = 1) and right intercostobronchial trunk (n = 1). The embolic agents utilized included microcoils (n = 1), gelatin sponge particles (n = 2), polyvinyl alcohol (PVA) with gelatin sponge particles (n = 1), PVA with microcoils (n = 1), microcoils with gelatin sponge particles (n = 1), and microcoils with n-butyl-2-cyanoacrylate and gelatin sponge particles (n = 1). The 30-day mortality rate was 14% (1/7). No ischemic complications related to TAE were observed. CONCLUSION: The study suggests that TAE is safe and effective for controlling hemodynamically unstable bleeding following a PTNB.

Spontaneous large volume hemothorax managed with a small-bore chest tube.

A 67-year-old male with metastatic lung cancer presented with acute shortness of breath and increasing oxygen requirements. He had a decreasing hemoglobin for which he required red blood cell transfusions. His chest X-ray showed near complete white-out of the left lung. Bedside ultrasound (Handheld Sonostar C4PL) showed a large pleural effusion with swirling echogenic material suggestive of plankton sign. The pleural effusion was aspirated and showed frank blood, after which a small-bore chest tube (SBCT) was inserted. A total of 3200 mL of blood was drained with the SBCT. There was complete clearance of the pleural space, and no further blood product transfusions were needed. This case highlights that conservative management can be considered in patients with spontaneous hemothorax due to metastatic disease.

[Chest Tube in Thoracic Trauma - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU)]. / Thoraxdrainage beim Thoraxtrauma ­ Empfehlungen der interdisziplinären Arbeitsgemeinschaft Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und der Deutschen Gesellschaft für Unfallchirurgie (DGU).

For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH2O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.

Application of contrast-enhanced ultrasound in hemothorax of hereditary hemorrhagic telangiectasia: A case report and literature review.

Hereditary hemorrhagic telangiectasis (HHT) is an autosomal dominant hereditary disease, which can lead to abnormal angiogenesis. We performed contrast-enhanced ultrasound (CEUS) in a patient with HHT represented with hemothorax. After targeted embolization, the condition of hemothorax improved. In this case, we explore the use of CEUS to locate the responsible vessel of hemothorax, and found that CEUS could be used as a complementary preoperative method of localization with computed tomography angiography (CTA).