Chest Tube Size Selection: Evaluating Provider Practices, Treatment Efficacy, and Complications in Management of Thoracic Trauma.

BACKGROUND: The standard for managing traumatic pneumothorax (PTX), hemothorax (HTX), and hemopneumothorax (HPTX) has historically been large-bore (LB) chest tubes (>20-Fr). Previous studies have shown equal efficacy of small-bore (SB) chest tubes (≤19-Fr) in draining PTX and HTX/HPTX. This study aimed to evaluate provider practice patterns, treatment efficacy, and complications related to the selection of chest tube sizes for patients with thoracic trauma. METHODS: A retrospective chart review was performed on adult patients who underwent tube thoracostomy for traumatic PTX, HTX, or HPTX at a Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between SB and LB thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern. Secondary outcomes included retained hemothorax, insertion-related complications, and duration of chest tube placement. Univariate and multivariate analyses were performed. RESULTS: Three hundred and forty-one patients were included and 297 (87.1%) received LB tubes. No significant differences were found between the groups concerning tube failure and insertion-related complications. LB tubes were more frequently placed in patients with penetrating MOI, higher average ISS, and higher average thoracic AIS. Patients who received LB chest tubes experienced a higher incidence of retained HTX. DISCUSSION: In patients with thoracic trauma, both SB and LB chest tubes may be used for treatment. SB tubes are typically placed in nonemergent situations, and there is apparent provider bias for LB tubes. A future randomized clinical trial is needed to provide additional data on the usage of SB tubes in emergent situations.

A retrospective multi-institutional survey of characteristics of surgically treated spontaneous hemopneumothorax patients.

OBJECTIVE: The Japan Society for Pneumothorax and Cystic Lung Disease conducted a nationwide retrospective survey to identify correlations between the timing of surgical intervention and the incidence of transfusion, and to examine the factors contributing to the need for transfusion among clinical features in surgically treated spontaneous hemopneumothorax (SHP) patients. METHODS: We analyzed the characteristics and perioperative results of patients with SHP who underwent thoracoscopy or thoracotomy between April 2009 and March 2019. RESULTS: From 17 institutions, 171 cases were enrolled in this study. Receiver-operating characteristic curve analyses for the incidence of transfusion and waiting time before the operation revealed an area under the curve of 0.54 (95% confidence interval [CI] 0.44-0.64). Therefore, we did not compare the clinical features using a cutoff value of waiting time before the operation. More than 80% of the patients underwent surgical treatment within 24 h from admission. Multivariate analysis revealed that the total volume of hemorrhage was the only significant factor contributing to the incidence of transfusion (p = 0.00011, odds ratio: 0.03, 95% CI 0.0051-0.18). Moreover, multivariate analyses revealed that the waiting time before the operation was a contributing factor for prolonged total hospitalization (p < 0.0001, estimated regression coefficient: 0.036, 95% CI 0.027-0.045). CONCLUSION: In SHP patients, a reduction in the waiting time before the operation significantly contributed to not the avoidance of transfusion but a reduction in total hospitalization time. In addition, transfusion was performed depending on the volume of blood loss.

Spontaneous hemopneumothorax with a ruptured aneurysm in the second intercostal artery: report of a case.

Ruptured intercostal aneurysm is a rare cause of spontaneous hemopneumothorax (SHP). A 29-year-old woman presented to our hospital with left neck pain and, in the emergency room, suddenly lost consciousness. Chest radiography showed massive pleural effusion and the moderate collapse of the left lung. A chest drain was placed and 800 mL of bloody pleural effusion was collected. Contrast-enhanced computed tomography showed a ruptured aneurysm near the left pulmonary apex. Emergency angiography further revealed the ruptured aneurysm in the second intercostal artery. Transcatheter angiographic embolization (TAE) was performed, which resulted in hemostasis. On hospitalization day 2, the hematoma was removed via video-assisted thoracic surgery. A bulla was also identified in the lower lobe and removed. She was discharged from the hospital on a postoperative day 6 without complications. Thus, TAE might be effective to control bleeding during the initial treatment of SHP due to a ruptured aneurysm.

Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax.

INTRODUCTION: Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32-40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX. METHODS: Prospective RCT comparing 14Fr PCs to 28-32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1-5 (1 = tolerable experience, 5 = worst experience). Unpaired Student's t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P < 0.05. RESULTS: Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375-1087; for PCs vs. 400 ml; IR, 240-700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, "I can tolerate it"; IR, 1-2) than CT patients (median, 3, "It was a bad experience"; IR, 3-4, P = 0.001). CONCLUSION: In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28-32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience. www.ClinicalTrials.gov Registration ID: NCT02553434.

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.

Spontaneous hemopneumothorax in a patient with COVID-19.

Coronavirus disease 2019 (COVID-19) is primarily a febrile respiratory illness that was first documented in China in December 2019 and shortly after declared a pandemic on March 11, 2020. The pathophysiology of the virus is still not completely understood and remains under investigation. Consequently, new symptomatic manifestations and complications of the disease continue to be discovered. Here we present the case of a spontaneous hemopneumothorax resulting in hemorrhagic shock in an adult male with PCR confirmed COVID-19.

[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.

A rare cause of recurrent hemopneumothorax.

Background: Angiosarcoma is a rare and aggressive tumor of vascular endothelial origin. Pulmonary metastasis can lead to potential life-threatening complications, such as bleeding and pneumothorax.Methods: We report on a 82-year-old male with major hemoptysis, recurrent hemopneumothorax and cystic lung lesions.Results: Although initial diagnostic findings were misleading, thoracoscopic exploration revealed pulmonary and pleural metastasized angiosarcoma.Conclusion: The presence of hemoptysis or (recurrent) hemopneumothorax associated with cystic lung lesions should alert the clinician of possible pulmonary metastasized angiosarcoma.

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.

Accidental neck and chest penetration by a metal sliver derived from an axe for wood chopping: a case report.

BACKGROUND: Penetrating neck and chest trauma is a very common entity in emergency medicine that usually requires surgical treatment. Our case report illustrates the case of a 27-year-old Arabian man with hemopneumothorax associated with pneumomediastinum due to an unusual occupational injury. CASE PRESENTATION: A metal sliver, coming from an axe using for wood chopping, penetrated the neck of a 27-year-old Arabian man in the left supraclavicular region mimicking a gun bullet; the entrance hole was at the left pleural dome where the sliver had just penetrated the apex of the lung passing through the upper lobe of his left lung creating an exit wound in the dorsal segment of the same lobe arriving in the posterior thoracic wall. Biportal video-assisted thoracic surgery was performed to remove blood clots and the unusual foreign body.  CONCLUSION: In the literature, there are several case series about this topic, with some of them reporting unusual foreign bodies that lead to penetrating trauma. However, to the best of our knowledge, no cases like the one we have reported are described in the current literature.

Severe haemophilia A in a neonate presenting as haemopneumothorax after tracheo-oesophageal fistula-oesophageal atresia repair.

A male infant with oesophageal atresia and distal tracheo-oesophageal fistula (TEF type C) underwent right thoracotomy and transpleural repair of TEF on day 4 of life. He did not have a family history of coagulation disorders. A preoperative finding of prolonged partial thromboplastin time (PTT)>200 s was overlooked, and he went to surgery. There were no concerns with haemostasis prior to and even during the operation. The prolonged PTT was treated with one 10 mL/kg dose of fresh frozen plasma in the immediate postoperative period. On the fourth postoperative day, the infant developed a right haemopneumothorax, requiring fresh frozen plasma and packed cell transfusions. He was subsequently diagnosed with severe haemophilia A due to intron 22 inversion in the factor VIII gene, with factor VIII level <0.01 IU/mL.

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.

A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax/Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter.

BACKGROUND: The effectiveness of 14-French (14F) pigtail catheters (PCs) compared to 32-40F chest tubes (CTs) in patients with traumatic hemothorax (HTX) and hemopneumothorax (HPTX) is becoming more well known but still lacking. The aim of our study was to analyze our cumulative experience and outcomes with PCs in patients with traumatic HTX/HPTX. We hypothesized that PCs would be as effective as CTs. METHODS: Using our PC database, we analyzed all trauma patients who required chest drainage for HTX/HPTX from 2008 to 2014. Primary outcomes of interest, comparing PCs to CTs, included initial drainage output in milliliters (mL), tube insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t test, Chi-square test, and Wilcoxon rank-sum test. We defined statistical significance as P < 0.05. RESULTS: During the 7-year period, 496 trauma patients required chest drainage for traumatic HTX/HPTX: 307 by CTs and 189 by PCs. PC patients were older (52 ± 21 vs. 42 ± 19, P < 0.001), demonstrated a significantly higher occurrence of blunt trauma (86 vs. 55%, P ≤ 0.001), and had tubes placed in a non-emergent fashion (Day 1 [interquartile range (IQR) 1-3 days] for PC placement vs. Day 0 [IQR 0-1 days] for CT placement, P < 0.001). All primary outcomes of interest were similar, except that the initial drainage output for PCs was higher (425 mL [IQR 200-800 mL] vs. 300 mL [IQR 150-500], P < 0.001). Findings for subgroup analysis among emergent and non-emergent PC placement were also similar to CT placement. CONCLUSION: PCs had similar outcomes to CTs in terms of failure rate and tube insertion-related complications, and the initial drainage output from PCs was not inferior to that of CTs. The usage of PCs was, however, selective. A future multi-center study is needed to provide additional support and information for PC usage in traumatic HTX/HPTX.

Bigger is better: Comparison of alternative devices for tension hemopneumothorax and pulseless electrical activity in a Yorkshire swine model.

BACKGROUND: Tension pneumothorax is a cause of potentially preventable death in prehospital and battlefield settings and 14-gauge angiocatheter (14G AC) decompression remains the current treatment standard, despite its high incidence of failure. Traumatic pneumothorax is often associated with hemothorax, but 14G AC has no proven efficacy for associated hemothorax. We sought to compare the 14G AC to three alternative devices for treatment of tension hemopneumothorax (t-H/PTX) in a positive-pressure ventilation swine model. METHODS: Our tension model was modified to incorporate a persistent air leak and pleural blood. Tension physiology was achieved with escalating carbon dioxide insufflation via transdiaphragmatic trocar, and 10% estimated blood volume was instilled into each chest. Intervention was randomized between 14G AC, 10-gauge angiocatheter (10G AC), modified Veress-type needle (mVN), and 3-mm laparoscopic trocar (LT). After recovery, serial tension-induced pulseless electrical activity (PEA) events were induced and decompressed. Success of rescue, time to rescue, and physiologic data were recorded. RESULTS: One hundred ninety-five t-H/PTX and 88 PEA events were conducted in 25 swine. Laparoscopic trocar and 10G AC were more successful and had faster median time to rescue for t-H/PTX compared with 14G AC, whereas mVN performed comparably. Following PEA, 14G AC and mVN succeeded at rescue only 50% and 57% of the time, whereas 10G AC and LT had 100% success at return of spontaneous circulation. Time to successful return of circulation following PEA did not differ between devices; however, there was a noticeable difference in the rate of meaningful hemodynamic recovery following PEA favoring LT and 10G AC. There were no significant injuries noted. CONCLUSIONS: While mVN performed comparably to 14G AC, both have unacceptable failure rates. Ten-gauge AC and LT performed superiorly in both t-H/PTX and PEA. We believe there is now ample evidence supporting replacement of the 14G AC with 10G AC in current treatment recommendations.