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Delayed Massive Hemothorax Due to a Diaphragmatic Laceration Associated With Lower Rib Fractures. A Penetrating Injury in Blunt Trauma
Hemotórax masivo tardío por laceración diafragmática asociado a fracturas costales inferiores. Una herida penetrante en el traumatismo cerrado
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A Penetrating Injury in Blunt Trauma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e73" "paginaFinal" => "e75" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juan José Segura Sampedro, Francisco García Gómez, Laura Arroyo Pareja, Sandra Liliana Pardo Prieto, Nicolás Moreno Mata" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Juan José" "apellidos" => "Segura Sampedro" "email" => array:1 [ 0 => "segusamjj@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Francisco" "apellidos" => "García Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Laura" "apellidos" => "Arroyo Pareja" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Sandra Liliana" "apellidos" => "Pardo Prieto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Nicolás" "apellidos" => "Moreno Mata" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "UGC Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Torácica, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemotórax masivo tardío por laceración diafragmática asociado a fracturas costales inferiores. Una herida penetrante en el traumatismo cerrado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 667 "Ancho" => 750 "Tamanyo" => 44690 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph after 48<span class="elsevierStyleHsp" style=""></span>h: rapid progression with opacification of 2/3 of the left hemithorax.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Approximately 70%–75% of traumatic haemothorax can be managed with chest tubes.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Only 15% of blunt trauma injuries require emergency surgery.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The estimated incidence of diaphragm injury is 5% in patients who are hospitalised with blunt thoracoabdominal trauma, and some 50% of these cases go unnoticed during the initial examination at admittance. Up to 8% of patients who undergo urgent thoracotomy after blunt trauma present a diaphragm lesion that had initially gone undetected.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Almost all cases diagnosed in the acute phase are associated with one or several organ lesions that are life-threatening. Rapid assessment of the patient's clinical situation is necessary, along with meticulous observation of chest radiographs. This is especially true in the case of penetrating wounds in blunt chest trauma, as in the case we present.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case Report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 50-year-old male was treated in the Emergency Department due to thoracic pain and dyspnoea after thoracoabdominal trauma that occurred when getting out of the bathtub. The patient reported no cranial trauma or injuries to other areas. Prior to the accident, the patient had been healthy and had no medical history of interest. He smoked 2 packs/day and had no other toxic habits.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At admittance, the patient was conscious and oriented (Glasgow 15); blood pressure (BP) was 114/68<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 98<span class="elsevierStyleHsp" style=""></span>bpm, baseline SO<span class="elsevierStyleInf">2</span> 95 and glycemia 112<span class="elsevierStyleHsp" style=""></span>mg/dL.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Physical examination showed a permeable airway and sharp pain in the ribs during inspiration, with crepitation of the left ribcage and no observed flail chest. Cardiorespiratory auscultation was normal with audible vesicular murmur.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Lab work showed: haemoglobin (Hb) 170<span class="elsevierStyleHsp" style=""></span>g/L and 17.84×109<span class="elsevierStyleHsp" style=""></span>leukocytes/L. On chest radiography, unipolar fractures were observed in the left ribs (5th–9th) with no consolidations, collections or signs of pneumothorax. Thoracoabdominal CT scan with intravenous contrast confirmed these rib fractures and that the 5th, 6th and 7th were displaced. Mild oedema and emphysema of the wall were observed with minimal left pleural effusion. There were no images of pneumothorax, signs of laceration or important foci of pulmonary contusion. There were also no abdominal findings of interest.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was hospitalised for further monitoring and analgesia. After 72<span class="elsevierStyleHsp" style=""></span>h, the patient started to sit up. There was a fall of 25<span class="elsevierStyleHsp" style=""></span>g/L in Hb compared to the levels at admittance. The patient had episodes of severe hypotension and bradycardia of up to 45<span class="elsevierStyleHsp" style=""></span>lpm, which initially responded to fluids and Trendelenburg position. Auscultation showed abolition of the vesicular murmur in the lower two-thirds of the left hemithorax. Chest radiograph showed evidence of moderate-severe pleural effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A chest drain tube was placed in the 5th intercostal space on the anterior axillary midline according to the standard technique, and 1700<span class="elsevierStyleHsp" style=""></span>cc of blood were immediately collected. Simultaneously, the patient had another hypotensive episode, which he overcame with fluid therapy. Another chest radiograph verified the correct placement of the chest drain but no lung re-expansion. Blood work showed Hb 70<span class="elsevierStyleHsp" style=""></span>g/L, which was a drop of 100<span class="elsevierStyleHsp" style=""></span>g/L since hospitalisation. Given these findings and the haemodynamic instability of the patient, urgent exploratory thoracotomy was indicated when the drained content had already reached 2100<span class="elsevierStyleHsp" style=""></span>cc.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Lateral thoracotomy was performed in the 5th intercostal space, and a massive haemothorax was evacuated (1500<span class="elsevierStyleHsp" style=""></span>cc) with abundant lavage. We confirmed displaced fractures of the 5th to 7th ribs. The 7th had splintered edges, with one of the edges aimed towards the diaphragm and laceration of its corresponding dome measuring 4<span class="elsevierStyleHsp" style=""></span>cm, which was bleeding profusely (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Haemostasis was achieved by means of a diaphragm transfixion suture and continuous suture of the tear with PremiCron<span class="elsevierStyleSup">®</span> 0 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), followed by abundant lavage. We inspected the lung and found no injury. The rib edges were trimmed and smoothed. Chest wall closure was performed with the insertion of 2 chest drains.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The patient remained stable during surgery and required 1500<span class="elsevierStyleHsp" style=""></span>cc crystalloids and the transfusion of 3 units of blood.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient stayed in the ICU for 24<span class="elsevierStyleHsp" style=""></span>h, where he was haemodynamically stable. On the hospital ward, his condition continued to improve and the patient was discharged on the 4th day after surgery with normalised parameters. At the follow-up visit 1 month later, no complications were observed.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Massive haemothorax involves the sudden accumulation of more than 1500<span class="elsevierStyleHsp" style=""></span>cc of blood or one-third the patient's blood volume in the thoracic cavity.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> This condition, although more frequent in open trauma, can go unnoticed in blunt trauma and therefore requires a high index of suspicion.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Massive haemothorax also involves comprised respiratory function due to the deficient lung expansion that impedes adequate ventilation and hypoxaemia. This situation, together with the accompanying hypovolemic shock, is life-threatening.</p><p id="par0070" class="elsevierStylePara elsevierViewall">During the examination of multiple trauma patients, haemodynamic instability associated with hypovolemic shock, accompanied by absence of vesicular murmur and dullness to percussion in the hemithorax, are diagnostic of massive haemothorax (all of which were present in this case).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Chest radiography can confirm the initial diagnosis and provides early assessment of the correct placement of the chest tube as well as lung re-expansion once the haemothorax is drained. Measurement of Hb enables us to easily determine the estimated blood loss and it is a fundamental parameter that contributes to better blood volume replacement with transfusion of blood products, if necessary. The use of CT scans in massive haemothorax is excluded because of the patient instability with this condition.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Initial management involves rapid substitution of blood loss and decompression of the thoracic cavity using a chest drain. Drainage of more than 1500<span class="elsevierStyleHsp" style=""></span>cc of blood or 200<span class="elsevierStyleHsp" style=""></span>mL/h in 2–4<span class="elsevierStyleHsp" style=""></span>h are criteria for urgent thoracotomy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> In the case we report, there was an immediate evacuation of 1700<span class="elsevierStyleHsp" style=""></span>cc after chest tube insertion, the imaging study confirmed the lack of lung re-expansion, and the haemodynamic instability of the patient all indicated emergency exploratory thoracotomy.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The selection of the surgical approach is essential in this situation and is defined by the initial suspicion of the injury and the understanding of the exposure offered by the incision.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> In our case, we theorised that the source of the haemorrhage could be the diaphragm lesion or the displaced rib fractures.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The approach we chose was lateral thoracotomy in the 5th intercostal space, which provided good visualisation of the diaphragm surface and rib fractures in order to control any bleeding and for stabilisation. It also enabled us to explore the entire chest cavity, parenchyma and hilum in order to rule out any concomitant injuries.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Cases of massive, late-onset and sudden haemothorax described in the literature are always associated with displaced lower rib fractures. The injury mechanism in diaphragm laceration caused by the stabbing action of a displaced rib has been described as a “penetrating injury in blunt trauma”.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> During blunt trauma, the increased intraabdominal pressure forces the diaphragm upwards, where it comes into contact with the fractured rib edge, which cuts the diaphragm like a knife. In the case we report, sitting up and moving led to increased intraabdominal pressure and an approximation of the diaphragm dome to the bone fracture, causing this “penetrating injury in the context of blunt trauma”.</p><p id="par0095" class="elsevierStylePara elsevierViewall">We conclude that, in patients with multiple trauma injuries and displaced lower rib fractures,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> undetected diaphragm injuries can result in massive haemothorax, especially when the patient starts to move and the pain is disguised by the fractured rib pain.</p><p id="par0100" class="elsevierStylePara elsevierViewall">It is essential to always monitor early signs of hypovolemic shock and maintain a high index of suspicion. The chest should be studied in detail, as the pain from the rib trauma can camouflage injury to the diaphragm. When faced with a situation of haemodynamic instability associated with compatible examination, drastic drop in Hb in a discharge of more than an initial 1500<span class="elsevierStyleHsp" style=""></span>c or more than 200<span class="elsevierStyleHsp" style=""></span>cc/h in 2–4<span class="elsevierStyleHsp" style=""></span>h, urgent thoracotomy is indicated and should not be delayed.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,8</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Segura Sampedro JJ, García Gómez F, Arroyo Pareja L, Pardo Prieto SL, Moreno Mata N. Hemotórax masivo tardío por laceración diafragmática asociado a fracturas costales inferiores. Una herida penetrante en el traumatismo cerrado. Cir Esp. 2015;93:e73–e75.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 667 "Ancho" => 750 "Tamanyo" => 44690 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph after 48<span class="elsevierStyleHsp" style=""></span>h: rapid progression with opacification of 2/3 of the left hemithorax.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 997 "Ancho" => 750 "Tamanyo" => 115007 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diaphragm laceration with active haemorrhage after evacuating the haemothorax.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 593 "Ancho" => 750 "Tamanyo" => 88196 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Exposure and suture of diaphragm tear; bleeding was already controlled.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Drenaje torácico: neumotórax y hemotórax traumáticos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 16 | 9 | 25 |
| 2024 September | 60 | 11 | 71 |
| 2024 August | 43 | 14 | 57 |
| 2024 July | 78 | 18 | 96 |
| 2024 June | 71 | 4 | 75 |
| 2024 May | 73 | 8 | 81 |
| 2024 April | 69 | 5 | 74 |
| 2024 March | 75 | 6 | 81 |
| 2024 February | 65 | 5 | 70 |
| 2024 January | 82 | 11 | 93 |
| 2023 December | 62 | 3 | 65 |
| 2023 November | 94 | 9 | 103 |
| 2023 October | 126 | 12 | 138 |
| 2023 September | 56 | 5 | 61 |
| 2023 August | 71 | 3 | 74 |
| 2023 July | 72 | 6 | 78 |
| 2023 June | 68 | 7 | 75 |
| 2023 May | 112 | 10 | 122 |
| 2023 April | 101 | 2 | 103 |
| 2023 March | 93 | 11 | 104 |
| 2023 February | 75 | 4 | 79 |
| 2023 January | 48 | 7 | 55 |
| 2022 December | 49 | 8 | 57 |
| 2022 November | 69 | 14 | 83 |
| 2022 October | 47 | 8 | 55 |
| 2022 September | 48 | 20 | 68 |
| 2022 August | 52 | 22 | 74 |
| 2022 July | 35 | 10 | 45 |
| 2022 June | 32 | 6 | 38 |
| 2022 May | 41 | 9 | 50 |
| 2022 April | 44 | 11 | 55 |
| 2022 March | 45 | 15 | 60 |
| 2022 February | 31 | 11 | 42 |
| 2022 January | 49 | 6 | 55 |
| 2021 December | 48 | 12 | 60 |
| 2021 November | 40 | 12 | 52 |
| 2021 October | 43 | 14 | 57 |
| 2021 September | 35 | 26 | 61 |
| 2021 August | 35 | 11 | 46 |
| 2021 July | 26 | 12 | 38 |
| 2021 June | 18 | 6 | 24 |
| 2021 May | 26 | 13 | 39 |
| 2021 April | 137 | 15 | 152 |
| 2021 March | 82 | 7 | 89 |
| 2021 February | 68 | 10 | 78 |
| 2021 January | 57 | 18 | 75 |
| 2020 December | 44 | 11 | 55 |
| 2020 November | 54 | 11 | 65 |
| 2020 October | 30 | 9 | 39 |
| 2020 September | 39 | 13 | 52 |
| 2020 August | 52 | 7 | 59 |
| 2020 July | 49 | 10 | 59 |
| 2020 June | 25 | 14 | 39 |
| 2020 May | 57 | 21 | 78 |
| 2020 April | 40 | 10 | 50 |
| 2020 March | 43 | 4 | 47 |
| 2020 February | 49 | 14 | 63 |
| 2020 January | 29 | 6 | 35 |
| 2019 December | 42 | 11 | 53 |
| 2019 November | 41 | 3 | 44 |
| 2019 October | 34 | 8 | 42 |
| 2019 September | 32 | 8 | 40 |
| 2019 August | 23 | 8 | 31 |
| 2019 July | 18 | 36 | 54 |
| 2019 June | 34 | 24 | 58 |
| 2019 May | 85 | 55 | 140 |
| 2019 April | 37 | 27 | 64 |
| 2019 March | 8 | 2 | 10 |
| 2019 February | 8 | 11 | 19 |
| 2019 January | 1 | 4 | 5 |
| 2018 December | 9 | 9 | 18 |
| 2018 November | 10 | 2 | 12 |
| 2018 October | 10 | 3 | 13 |
| 2018 September | 4 | 5 | 9 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 8 | 0 | 8 |
| 2018 June | 4 | 1 | 5 |
| 2018 May | 3 | 1 | 4 |
| 2018 April | 13 | 3 | 16 |
| 2018 March | 2 | 0 | 2 |
| 2018 February | 9 | 1 | 10 |
| 2018 January | 19 | 4 | 23 |
| 2017 December | 5 | 1 | 6 |
| 2017 November | 17 | 2 | 19 |
| 2017 October | 11 | 2 | 13 |
| 2017 September | 13 | 3 | 16 |
| 2017 August | 15 | 3 | 18 |
| 2017 July | 20 | 2 | 22 |
| 2017 June | 23 | 1 | 24 |
| 2017 May | 28 | 2 | 30 |
| 2017 April | 32 | 0 | 32 |
| 2017 March | 19 | 38 | 57 |
| 2017 February | 25 | 3 | 28 |
| 2017 January | 25 | 3 | 28 |
| 2016 December | 34 | 7 | 41 |
| 2016 November | 23 | 5 | 28 |
| 2016 October | 39 | 3 | 42 |
| 2016 September | 64 | 8 | 72 |
| 2016 August | 26 | 6 | 32 |
| 2016 July | 16 | 3 | 19 |
| 2016 June | 11 | 5 | 16 |
| 2016 May | 15 | 11 | 26 |
| 2016 April | 17 | 10 | 27 |
| 2016 March | 32 | 19 | 51 |
| 2016 February | 21 | 6 | 27 |
| 2016 January | 23 | 11 | 34 |
| 2015 December | 16 | 4 | 20 |
| 2015 November | 12 | 4 | 16 |
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