Papel de la ecografía en la sala de emergencia en el diagnóstico del trauma de tórax / The Role of Sonography in the Emergency Room for the Diagnosis of Thoracic Trauma

Introducción: Dentro de la atención al lesionado con trauma torácico se cuenta con varios medios diagnósticos, entre ellos la evaluación por ecografía focalizada en trauma extendido a tórax, el cual ha mostrado una alta sensibilidad, aun realizado por médicos no radiólogos como cirujanos generales, emergencistas e intensivistas. Objetivo: Determinar la utilidad de la ecografía torácica extendida realizada por cirujanos en lesionados con traumatismo torácico. Métodos: Se realizó un estudio observacional, descriptivo de evaluación de pruebas diagnósticas con un diseño transversal, en 1052 pacientes ingresados en la sala de emergencia. Se les realizó la evaluación por ecografía torácica extendida en el Hospital Universitario "General Calixto García", durante el período comprendido entre enero de 2020 y febrero de 2021. Resultados: Fueron realizados en un periodo de 1 año un total de 1052 ultrasonidos torácicos, 221 casos fueron positivos, de ellos 81 neumotórax (7,7 por ciento) y 62 hemoneumotórax (5,9 por ciento) todos confirmados por tomografía de tórax. La edad promedio fue de 45,27 (18-97), el sexo masculino prevaleció con 772 casos (73,4 por ciento). Los mecanismos productores de trauma más frecuentes fueron: caída de altura 273 casos (26 por ciento) y trauma contuso 181 casos (17,2 por ciento). La ecografía torácica extendida obtuvo una sensibilidad de un 95,24 por ciento y una especificidad de 99,88 por ciento en el diagnóstico lesiones torácicas. Conclusiones: La ecografía torácica extendida demostró que en manos de los cirujanos generales es una herramienta confiable, segura, no invasiva, poco costosa, repetible, que permite diagnosticar rápidamente lesiones torácicas y tratarlas(AU)

Introduction: Within care for the injured patient with thoracic trauma there are several diagnostic means. For example, extended focused assessment with sonography for thoracic trauma has shown high sensitivity, even when performed by non-radiologists such as general surgeons, emergency specialists and intensivists. Objective: To determine the usefulness of extended thoracic sonography performed by surgeons on injured patients with thoracic trauma. Methods: An observational, descriptive and cross-sectional study of diagnostic tests assessment was carried out in 1052 patients admitted to the emergency room. They were assessed by extended thoracic sonography at General Calixto García University Hospital, during the period between January 2020 and February 2021. Results: A total of 1052 thoracic ultrasounds were performed in a period of one year, of which 221 cases were positive. Of them, 81 were pneumothorax (7.7 percent) and 62 were hemopneumothorax (5.9 percent), all confirmed by chest tomography. The average age was 45.27 (18-97). The male sex prevailed, with 772 cases (73.4 percent). The most frequent trauma-producing mechanisms were altitude fall, accounting for 273 cases (26 percent), and blunt trauma, accounting for 181 cases (17.2 percent). Extended thoracic ultrasound showed a sensitivity of 95.24 percent and a specificity of 99.88 percent in the diagnosis of thoracic injuries. Conclusions: Extended thoracic ultrasound showed that, in the hands of general surgeons, it is a reliable, safe, noninvasive, inexpensive and repeatable tool that allows rapid diagnosis and treatment of thoracic injuries(AU)

[Contralateral Pneumothorax after Surgery for Idiopathic Hemopneumothorax;Report of a Case].

A 17-year-old man came to the hospital complaining of right back pain. He had a history of an emergency operation for a left idiopathic hemopneumothorax. A chest X-ray revealed right lung collapse and suggested pleural adhesion at the apex of the right lung. He was diagnosed with right spontaneous pneumothorax and the surgical treatment was performed, because pleural adhesion may cause the hemothorax. During surgery, several pleural adhesion bands were found in the thoracic cavity between the right lung apex and chest wall. Spontaneous pneumothorax with a pleural adhesion at the apex is considered to be the indication for surgery because of the risk of hemothorax.

Spontaneous hemopneumothorax after laparoscopy: a case report and literature review.

BACKGROUND: Spontaneous hemopneumothorax (SHP) is defined as the accumulation of >400 mL of blood in the pleural cavity in association with spontaneous pneumothorax. This rare clinical disorder may be life-threatening. CASE PRESENTATION: A 71-year-old woman presented with a 1-month history of recurrent bloody stool, and electronic colonoscopy suggested a rectal mass. Laparoscopic radical resection of rectal cancer was performed. Two days later, she developed chest tightness, shortness of breath, and slight pain in the left chest. Emergency chest radiography revealed mild left pneumothorax and pleural effusion. SHP was suspected and a thoracic drain was inserted. However, the patient developed hemorrhagic shock 3 hours after drainage. She underwent emergency video-assisted thoracic surgery (VATS), which revealed left lung tip rupture with bleeding and adhesive band fracture at the top of the left thoracic cavity. The ruptured lung tissue was removed and electrocoagulation at the adhesion band was performed for hemostasis. The patient was discharged on postoperative day 11. At the time of this writing, she had developed no SHP recurrence or any other complications. CONCLUSIONS: This case shows that conservative treatment may have serious consequences in patients with SHP. Thus, chest X-ray examination and VATS should be performed in patients with SHP.

Hemopneumothorax After Trigger Point Injection for Fibromyalgia.

CONTEXT: Trigger point injections (TPIs) and acupuncture are common procedures in management of chronic back pain and usually are considered safe. Needling into cervical and thoracic regions can be associated with life-threatening complications. OBJECTIVE: The team intended to make practitioners aware of the potential for hemopneumothorax after TPI. DESIGN: The research team describes a case of hemopneumothorax after TPI. SETTING: The case study took place in the Department of Emergency Medicine at the Ankara University School of Medicine (Ankara, Turkey). PARTICIPANT: The participant was a 45-y-old woman, who had been admitted to the emergency department at the School of Medicine with dyspnea and dizziness after TPI for fibromyalgia. RESULTS: Computerized tomography of the thorax showed a significant hemopneumothorax at the right hemithorax and a collapsed right lung, markedly in the right, lower lobe. The hemopneumothorax was successfully treated with chest-tube and video-assisted thoracoscopic surgery. CONCLUSIONS: Health care professionals need to be aware of hemopneumothorax when performing TPI on the chest wall.

Pneumocephalus and pneumorachis after blunt chest trauma without spinal fractures: a case report.

BACKGROUND: Pneumocephalus and pneumorachis, presence of air inside the skull and spinal canal, are mostly seen after neurosurgical procedures and neuraxial anesthesia. They have also been described after penetrating trauma, but never after blunt trauma without adjacent bone fractures. CASE DESCRIPTION: We present the case of an 85-year-old white male patient admitted to our intensive care unit after a high velocity car accident. On site clinical evaluation showed normal consciousness with 15/15 Glasgow Coma Scale after a short initial loss of consciousness. The patient was first sent to a nearby hospital where a whole-body computed tomography scan revealed pneumocephalus and pneumorachis and an important left hemopneumothorax with pneumomediastinum with extensive subcutaneous emphysema. The state of the patient quickly worsened with hemorrhagic shock. The patient was sent to our intensive care unit; upon neurosurgical evaluation, no surgical indication was retained due to the absence of skull and spine fracture. A computed tomography scan performed on day 6 showed total regression of the pneumocephalus and pneumorachis. A follow-up computed tomography scan performed on day 30 revealed no intracranial bleeding or stroke, but a left pleural hernia between ribs 5 and 6. Due to respiratory complications, our patient could not be weaned from ventilator support for a proper neurological examination. Our patient's state finally worsened with septic shock due to ventilator-acquired pneumonia leading to multiple organ failure and our patient died on day 37. CONCLUSIONS: This is the first case report to describe pneumorachis and pneumocephalus following blunt trauma with pneumothorax, but no spinal or skull fractures. The mechanism that is probably involved here is a migration of air with subcutaneous emphysema and a pleural hernia into the spinal canal. However, in cases of pneumorachis or pneumocephalus, skull fractures need to be investigated as these require surgery and appropriate vaccination to prevent meningitis.

Hemopneumotórax recorrente: descrição da síndrome da endometriose torácica / Recurrent hemopneumothorax: thoracic endometriosis syndrome description

A endometriose torácica é uma forma de endometriose extrapélvica encontrada em tecidos pulmonares ou na pleura. Caracteriza- se clinicamente pela presença de pneumotórax catamenial, hemotórax catamenial, hemoptise e nódulos pulmonares. O pneumotórax catamenial é a manifestação mais frequente, sendo caracterizado pelo acúmulo recorrente de ar na cavidade torácica durante o período menstrual. Ocorre, geralmente, no hemitórax direito e possui maior incidência na faixa etária dos 30 aos 40 anos de idade. Nosso objetivo é descrever um caso de derrame pleural hemorrágico recorrente e pneumotórax espontâneo correlacionados ao período menstrual em paciente de 34 anos. (AU)

Thoracic endometriosis is a form of extrapelvic endometriosis found in pulmonary tissue or the pleura. Clinically, it is characterized by the presence of catamenial pneumothorax, catamenial hemothorax, hemoptysis, and pulmonary nodules. The most frequent clinical presentation is catamenial pneumothorax, which is typified by a recurrent collection of air in the thoracic cavity occurring in conjunction with menstrual periods. It occurs more commonly on the right side and its highest incidence is between 30 and 40 years of age. Our objective is to describe a case of recurrent hemorrhagic pleural effusion and spontaneous pneumothorax correlated to the menstrual period in a 34-year-old patient. (AU)

Video-tube thoracostomy in trauma resuscitation: A pilot study.

BACKGROUND: Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]). METHODS: A prospective, single centre, phase 1 pilot study with a parallel control group was undertaken. The population studied were adult thoracic trauma patients requiring emergency TT who were haemodynamically stable. The intervention performed was VTT. Patients in the control group underwent conventional TT. The primary outcome was tube position as defined by a consultant radiologist's interpretation of chest x-ray (CXR) or CT. The trial was registered with ANZCTR.org.au (ACTRN: 12,615,000,870,550). RESULTS: There were 37 patients enrolled in the study - 12 patients allocated to the VTT intervention group and 25 patients allocated to conventional TT. Mean age of participants was 48 years (SD 15) in intervention group and 46 years (SD 15) years in the control group. In the VTT group all patients were male; the indications were pneumothorax (83%), haemothorax (8%) and haemopneumothorax (8%). The median injury severity score was 23 (16-28). There were 1 positional and 1 insertional complications. In the control group 72% of patients were male, the indications were pneumothorax (56%), haemothorax (4%) and haemopneumothorax (40%). The median injury severity score was 24 (14-36). There were 8 (32%) positional complications and no insertional complications. CONCLUSION: V-TT was demonstrated to be a feasible alternative to conventional thoracostomy and merits further investigation.

Embolia grasa cerebral masiva tardía secundaria a politraumatismo grave / Delayed massive cerebral fat embolism secondary to severe polytrauma

No disponible

[Clinical Assessment of Spontaneous Hemopneumothorax].

We experienced 25 cases of spontaneous hemopneumothorax, in which 9 were defined as occult cases on chest X-ray at the time of visit. All 9 cases visited our hospital within 12 hours after the onset. Of these, 5 were done chest computed tomography (CT) and 3 could be diagnosed as hemopneumothorax. Emergency surgery were necessary in 4 of 9. Chest CT and careful observation is thought to be essential in case of suspiciously combined hemothorax in pneumothorax cases.

Unusual case of primary spontaneous hemopneumothorax in a young man with atypical tension pneumothorax: a case report.

BACKGROUND: Spontaneous life-threatening hemopneumothorax is an atypical but treatable entity of unexpected circulatory collapse in young patients, affecting 0.5-11.6% of patients with primary spontaneous pneumothorax. Spontaneous pneumothorax is a well-documented disorder with a classic clinical presentation of acute onset chest pain and shortness of breath. This disorder might be complicated by the development of hemopneumothorax or tension pneumothorax. CASE PRESENTATION: A 23-year-old Asian man was referred to the emergency room of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. A physical examination revealed a young man who was awake and alert but in mild to moderate painful distress. His vital parameters were relatively stable at first. The examining physician noted slight tenderness along the right posterolateral chest wall along the eighth and tenth ribs. Primary spontaneous pneumothorax was considered, and a standing chest X-ray confirmed the diagnosis. A right thoracostomy tube was immediately placed under sterile conditions, and he was referred to the respiratory service. While in the respiratory department, approximately 420 mL of blood was drained from the thoracostomy tube over 15 minutes. Our patient developed obvious hemodynamic instability with hypovolemic shock and was subsequently admitted to the cardiothoracic surgical ward after fluid resuscitation. During the ensuing 4 hours after admission, 750 mL of blood was drained through the thoracostomy tube. A bedside chest X-ray was requested after he was temporarily hemodynamically stabilized. Primary spontaneous hemopneumothorax associated with right tension pneumothorax was considered based on the radiological impression and clinical signs. An emergency limited posterolateral thoracotomy was performed. A standing chest X-ray performed on day 6 of admission after the removal of the thoracostomy tube showed a complete re-expansion of his right lung. He remained stable and was discharged within 1 week. CONCLUSIONS: The successful treatment of a large spontaneous hemopneumothorax depends on early recognition, proactive intervention, and early consideration by a cardiothoracic surgeon. Once the diagnosis is confirmed, early thoracotomy should be considered. Such an aggressive surgery not only leads to shorter hospitalization but also confers better long-term outcomes.

Malposition of a Central Venous Catheter in Trauma: Confirmation of Placement Prevents Complications.

This case study presents the inadvertent catheterization of a traumatic hemopneumothorax. A 22-year-old man sustained multiple stab wounds, including the left chest with a resultant hemopneumothorax. Upon arrival at a Level 1 trauma center, an ipsilateral subclavian central catheter was placed, blood was freely aspirated, and because of the patient's critical status, immediately utilized for resuscitation prior to line verification by radiography. A short time later, the catheter was felt to be malpositioned, most likely in the left intrathoracic space, and removed. The patient subsequently recovered and was discharged home 3 days later.

Resuscitative endovascular balloon occlusion of the aorta may increase the bleeding of minor thoracic injury in severe multiple trauma patients: a case report.

BACKGROUND: The resuscitative endovascular balloon occlusion of the aorta, because of its efficacy and feasibility, has been widely used in treating patients with severe torso trauma. However, complications developing around the site proximal to the occlusion by resuscitative endovascular balloon occlusion of the aorta have almost never been studied. CASE PRESENTATION: A 50-year-old Japanese woman fell from a height of approximately 10 m. At initial arrival, her respiratory rate was 24 breaths/minute, her blood oxygen saturation was 95% under 10 L/minute oxygenation, her pulse rate was 90 beats per minute, and her blood pressure was 180/120 mmHg. Mild lung contusion, hemopneumothorax, unstable pelvic fracture, and retroperitoneal bleeding with extravasation of contrast media were observed in initial computed tomography. As her vital signs had deteriorated during computed tomography, a 7-French aortic occlusion catheter (RESCUE BALLOON®, Tokai Medical Products, Aichi, Japan) was inserted and inflated for aortic occlusion at the first lumbar vertebra level and transcatheter arterial embolization was performed for the pelvic fracture. Her bilateral internal iliac arteries were embolized with a gelatin sponge; however, the embolized sites presented recanalization as coagulopathy appeared. Her bilateral internal iliac arteries were re-embolized by n-butyl-2-cyanoacrylate. The balloon was deflated 18 minutes later. After embolization, repeat computed tomography was performed and a massive hemothorax, which had not been captured on arrival, had appeared in her left pleural cavity. Thoracotomy hemostasis was performed and a hemothorax of approximately 2500 ml was aspirated to search for the source of bleeding. However, clear active bleeding was not captured; resuscitative endovascular balloon occlusion of the aorta may have been the cause of the increased bleeding of the thoracic injury at the proximal site of the aorta occlusion. CONCLUSIONS: It is necessary to note that the use of resuscitative endovascular balloon occlusion of the aorta may increase bleeding in sites proximal to occlusions, even in the case of minor injuries without active bleeding at the initial diagnosis.

[Reexpansion Pulmonary Edema during Emergency Surgery in a Patient with Spontaneous Hemopneumothorax].

A 43-year-old male patient with spontaneous hemopneumothorax of the right lung underwent emergency video-assisted thoracoscopic surgery for drainage, hemostasis and bullae resection. Fifteen minutes after reexpansion of the right lung, we found bubbly sputum coming out from the right tracheal tube and cloudy shadow in the right field of his chest X-ray. The occurrence of reexpansion pulmonary edema (RPE) was considered. Subsequent mechanical ventilation with PEEP and administration of steroid and diuretic was done as his treatment. His respiratory state was stabiized in the next two days. As the lung collapse following spontaneous hemopneumothorax often becomes more severe, we should pay attention to the occurrence of RPE after expansion of affected side lung. And, if it occurred, appropriate and prompt treatment as above should be done because of its high mortality.