[Outcomes of Surgical Treatment for Chest Trauma].

BACKGROUND: Intra-thoracic organ bleeding and chest wall injury following chest trauma can easily lead to life-threatening emergencies and a delay in treatment may lead to fatal outcomes. Interestingly, the optimal timing, indications, and surgical techniques have not been standardized. METHOD: We retrospectively analyzed 35 patients who underwent surgical treatment for chest trauma. RESULTS: All patients with penetrating trauma (n=4) underwent emergency surgery for a hemothorax. There were no postoperative complications or hospital deaths. All patients with blunt trauma( n= 31) had multiple rib fractures;rib fixation was performed in 29 patients( 94%). Eight patients( 26%) had flail chest. The duration from injury to surgery averaged 7.5 days. The prognosis was generally favorable with no postoperative complications, but two patients died in the hospital due to multiple organ failure caused by high-energy trauma. Patients with flail chest or multiple organ injury had prolonged postoperative hospital stays. CONCLUSIONS: Patients who sustain chest trauma follow various clinical courses. Appropriate timing of surgical intervention at an early stage after injury can be life saving and hasten a functional recovery.

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.

Analysis of thoracic trauma patients transferred to Türkiye's largest hospital after Kahramanmaras earthquake.

BACKGROUND: On February 6, 2023, an earthquake in Türkiye caused massive destruction. Over 50.000 people are known to have lost their lives, and over 100.000 are known to have been maimed. In our study, we aimed to analyze the treatment process of 267 METHODS: The demographic characteristics, the time spent under the rubble, the duration of transfer to the hospital, and the treatment process of patients admitted to our hospital have been evaluated. RESULTS: There are 125 (46.8%) men and 142 (53.2%) women in the study. The rate of thoracic trauma was 21.8%. Of all the patients, 15.7% (n=42) had pneumothorax, 18% (n=48) had contusion, 28.8% (n=77) had hemothorax, and 73% (n=195) had rib fractures. The mean time spent under the rubble was 17.6±26.5 h, the duration of transfer to the hospital was 138.5±113.6 h, and the hospitalization time was 93.8±152.3 h. The duration of hospitalization and transfer has been statistically longer for the patients who were under the rubble (85.4%) than for those who were not. (14.6%) (p=0.048). There is a statistically weak positive correlation between the time spent under the rubble and the time of transfer (p=0.048). CONCLUSION: The state, the time spent under the rubble, and the presence of hemothorax and pneumothorax should be effectively evaluated in earthquake-induced thoracic traumas. Considering these criteria in the transfer of patients to the centers operating at full capacity in a short time will minimize morbidity and mortality.

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.

Acupuncture-Induced Hemothorax with Hypovolemic Shock: A Case Report.

This report describes a very rare but life-threatening complication that occurred in a 43-year-old woman after an acupuncture (AC) for lumbago. The patient presented to the emergency department displaying symptoms indicative of shock. Physical examination revealed the absence of breath sounds on the right thoracic side, further investigations indicated the presence of a hemothorax. Emergency surgery was performed to evacuate the hemothorax and control bleeding from two intercostal veins. Although AC is often considered a gentle form of medicine, it is important to recognize that it can occasionally result in severe complications, especially when acupoints are used on the thorax.

Impact of intraoperative therapeutic plasma exchange on bleeding in lung transplantation.

BACKGROUND: Our program uses a desensitization protocol that includes intraoperative therapeutic plasma exchange (iTPE) for crossmatch-positive lung transplants, which improves access to lung transplant for sensitized candidates while mitigating immunologic risk. Although we have reported excellent outcomes for sensitized patients with the use of this protocol, concern for perioperative bleeding appears to have hindered broader adoption of it at other programs. We conducted a retrospective cohort study to quantify the impact of iTPE on perioperative bleeding in lung transplantation. METHODS: All first-time lung transplant recipients from 2014 to 2019 who received iTPE were compared to those who did not. Multivariable logistic regression was used to determine the association between iTPE and large-volume perioperative transfusion requirements (≥5 packed red blood cell units within 24 hours of transplant start), adjusted for disease type, transplant type, and extracorporeal membrane oxygenation or cardiopulmonary bypass use. The incidence of hemothorax (requiring reoperation within 7 days of lung transplant) and 30-day posttransplant mortality were compared between the 2 groups using chi-square test. RESULTS: One hundred forty-two patients (16%) received iTPE, and 755 patients (84%) did not. The mean number of perioperative pRBC transfusions was 4.2 among patients who received iTPE and 2.9 among patients who did not. iTPE was associated with increased odds of requiring large-volume perioperative transfusion (odds ratio 1.9; 95% confidence interval: 1.2-2.9, p-value = 0.007) but was not associated with an increased incidence of hemothorax (5% in both groups, p = 0.99) or 30-day posttransplant mortality (3.5% among patients who received iTPE vs 2.1% among patients who did not, p = 0.31). CONCLUSIONS: This study demonstrates that the use of iTPE in lung transplantation may increase perioperative bleeding but not to a degree that impacts important posttransplant outcomes.

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.

An audit of traumatic haemothoraces in a regional hospital in KwaZulu-Natal, South Africa.

BACKGROUND: Haemothorax occurs in approximately 60% of all thoracic and polytrauma cases and is responsible for 15-30% of all trauma mortalities. Penetrating injuries to the thorax are a common presentation in South African hospitals. This study aims to audit the traumatic haemothoraces and their outcomes in regional hospitals in Durban, KwaZulu-Natal, South Africa. METHODS: In this study, patient characteristics were grouped as either continuous or categorical variables. Continuous variables, such as age were summarised as means (with standard deviations) or medians (interquartile range [IQR]), as appropriate. Categorical variables such as sex were summarised as proportions. Fisher's exact test was used to compare proportions. All analyses were performed using the Statistical Package for Social Sciences. RESULTS: A total of 118 patients were included comprising 110 (93%) males and eight (7%) females, with an average age of 29.7 years. Stab-chest was the most frequent mechanism of injury (76; 64.4%), followed by gunshot wound (GSW)- chest (27; 22.9%) and isolated blunt chest trauma (9; 7.6%). Other mechanisms of injury were stab-neck (3; 2.5%), stab-shoulder (2; 1.7%) and blunt chest trauma in the context of polytrauma (1; 0.8%). The most frequent type of injury was penetrating (108; 91.5%), with only 10 (8.5%) cases of blunt injury. This study found that there was a statistically significant association between patient age groups and type of injury. CONCLUSION: Haemothorax is a common sequela of chest trauma. Retained haemothorax (RH) results in worsened patient outcomes including increased hospital length of stay (LOS). This study points to the need for auditing of proper intercostal chest drain (ICD) positioning, which is crucial for the successful drainage of 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.

Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study.

BACKGROUND: While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS: Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS: Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS: In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

Thoracic aortic dissection presenting with bilateral haemothoraces: a potentially missed diagnosis.

Thoracic aortic dissection is a life-threatening diagnosis, which should not be missed. We present a case in which a patient who presented to the emergency department with chest pain was assessed and referred for admission for treatment of pneumonia, due to misinterpretation of a chest radiograph finding. The patient was re-reviewed and subsequently underwent further investigation, which confirmed aortic dissection. She underwent emergency thoracic endovascular aortic graft repair with stent graft insertion. This case demonstrates haemothorax as an uncommon complication of aortic dissection.

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.

Single- Versus Dual-Chamber Implantable Cardioverter-Defibrillator for Primary Prevention of Sudden Cardiac Death in the United States.

Background Routine addition of an atrial lead during an implantable cardioverter-defibrillator (ICD) implantation for primary prevention of sudden cardiac death, in patients without pacing indications, was not shown beneficial in contemporary studies. We aimed to investigate the use and safety of single- versus dual-chamber ICD implantations in these patients. Methods and Results Using the National Inpatient Sample database, we identified patients with no pacing indications who underwent primary-prevention ICD implantation in the United States between 2015 and 2019. Sociodemographic and clinical characteristics, as well as in-hospital complications, were analyzed. Multivariable logistic regression was used to identify predictors of in-hospital complications. An estimated total of 15 940 patients, underwent ICD implantation for primary prevention of sudden cardiac death during the study period, 8860 (55.6%) received a dual-chamber ICD. The mean age was 64 years, and 66% were men. In-hospital complication rates in the dual-chamber ICD and single-chamber ICD group were 12.8% and 10.7%, respectively (P<0.001), driven by increased rates of pneumothorax/hemothorax (4.6% versus 3.4%; P<0.001) and lead dislodgement (3.6% versus 2.3%; P<0.001) in the dual-chamber ICD group. Multivariable analyses confirmed atrial lead addition as an independent predictor for "any complications" (odds ratio [OR], 1.1 [95% CI, 1.0-1.2]), for pneumo/hemothorax (odds ratio, 1.1 [95% CI, 1.0-1.4]), and for lead dislodgement (odds ratio, 1.3 [95% CI, 1.1-1.6]). Conclusions Despite lack of evidence for clinical benefit, dual-chamber ICDs are implanted for primary prevention of sudden cardiac death in a majority of patients who do not have pacing indication. This practice is associated with increased risk of periprocedural complications. Avoidance of routine implantation of atrial leads will likely improve safety outcomes.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis.

BACKGROUND: Traumatic hemothorax is common, and management failure leads to worse outcomes. We sought to determine predictive factors and understand the role of trauma center performance in hemothorax management failure. METHODS: We prospectively examined initial hemothorax management (observation, pleural drainage, surgery) and failure requiring secondary intervention in 17 trauma centers. We defined hemothorax management failure requiring secondary intervention as thrombolytic administration, tube thoracostomy, image-guided drainage, or surgery after failure of the initial management strategy at the discretion of the treating trauma surgeon. Patient-level predictors of hemothorax management failure requiring secondary intervention were identified for 2 subgroups: initial observation and immediate pleural drainage. Trauma centers were divided into quartiles by hemothorax management failure requiring secondary intervention rate and hierarchical logistic regression quantified variation. RESULTS: Of 995 hemothoraces in 967 patients, 186 (19%) developed hemothorax management failure requiring secondary intervention. The frequency of hemothorax management failure requiring secondary intervention increased from observation to pleural drainage to surgical intervention (12%, 22%, and 35%, respectively). The number of ribs fractured (odds ratio 1.12 per fracture; 95% confidence interval 1.00-1.26) and pulmonary contusion (odds ratio 2.25, 95% confidence interval 1.03-4.91) predicted hemothorax management failure requiring secondary intervention in the observation subgroup, whereas chest injury severity (odds ratio 1.58; 95% confidence interval 1.17-2.12) and initial hemothorax volume evacuated (odds ratio 1.10 per 100 mL; 95% confidence interval 1.05-1.16) predicted hemothorax management failure requiring secondary intervention after pleural drainage. After adjusting for patient characteristics in the logistic regression model for hemothorax management failure requiring secondary intervention, patients treated at high hemothorax management failure requiring secondary intervention trauma centers were 6 times more likely to undergo an intervention after initial hemothorax management failure than patients treated in low hemothorax management failure requiring secondary intervention trauma centers (odds ratio 6.18, 95% confidence interval 3.41-11.21). CONCLUSION: Failure of initial management of traumatic hemothorax is common and highly variable across trauma centers. Assessing patient selection for a given management strategy and center-level practices represent opportunities to improve outcomes from traumatic hemothorax.

Does preinjury anticoagulation worsen outcomes among traumatic hemothorax patients? A nationwide retrospective analysis.

INTRODUCTION: Up to a quarter of all traumatic deaths are due to thoracic injuries. Current guidelines recommend consideration of evacuation of all hemothoraces with tube thoracostomy. The aim of our study was to determine the impact of pre-injury anticoagulation on outcomes of traumatic hemothorax patients. MATERIALS AND METHODS: We performed a 4-year (2017 - 2020) analysis of the ACS-TQIP database. We included all adult trauma patients (age ≥18 years) presenting with hemothorax and no other severe injuries (other body regions <3). Patients with a history of bleeding disorders, chronic liver disease, or cancer were excluded from this study. Patients were stratified into two groups based on the history of preinjury anticoagulant use (AC, preinjury anticoagulant use: No-AC, no preinjury anticoagulant use). Propensity score matching (1:1) was done by adjusting for demographics, ED vitals, injury parameters, comorbidities, thromboprophylaxis type, and trauma center verification level. Outcome measures were interventions for hemothorax (chest tube, video-assisted thoracoscopic surgery [VATS]), reinterventions (chest tube > once), overall complications, hospital length of stay (LOS), and mortality. RESULTS: A matched cohort of 6,962 patients (AC, 3,481; No-AC, 3,481) was analyzed. The median age was 75 years, and the median ISS was 10. The AC and No-AC groups were similar in terms of baseline characteristics. Compared to the No-AC group, AC group had higher rates of chest tube placement (46% vs 43%, p = 0.018), overall complications (8% vs 7%, p = 0.046), and longer hospital LOS (7[4-12] vs 6[3-10] days, p ≤ 0.001). Reintervention and mortality rates were similar between the groups (p>0.05). CONCLUSION: The use of preinjury anticoagulants in hemothorax patients negatively impacts patient outcomes. Increased surveillance is required while dealing with hemothorax patients on pre-injury anticoagulants, and consideration should be given to earlier interventions for such patients.

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.