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Delayed Traumatic Hemothorax in Older Adults

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Open access Brief report Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2020-000626 on 8 March 2021. Downloaded from Complication to consider: delayed traumatic hemothorax in older adults Jeff Choi ,1 Ananya Anand ,1 Katherine D Sborov,2 William Walton,3 Lawrence Chow,4 Oscar Guillamondegui,5 Bradley M Dennis,5 David Spain,1 Kristan Staudenmayer1 ► Additional material is ABSTRACT very small hemothoraces rarely require interven- published online only. To view, Background Emerging evidence suggests older adults tion whereas larger hemothoraces often undergo please visit the journal online immediate drainage. However, emerging evidence (http:// dx. doi. org/ 10. 1136/ may experience subtle hemothoraces that progress tsaco- 2020- 000626). over several days. Delayed progression and delayed suggests HTX in older adults with rib fractures may development of traumatic hemothorax (dHTX) have not experience subtle hemothoraces that progress in a 1Surgery, Stanford University, been well characterized. We hypothesized dHTX would delayed fashion over several days.1 2 If true, older Stanford, California, USA be infrequent but associated with factors that may aid adults may be at risk of developing empyema or 2Vanderbilt University School of Medicine, Nashville, Tennessee, prediction. other complications without close monitoring. USA Methods We retrospectively reviewed adults aged ≥50 Delayed progression and delayed development of 3Radiology, Vanderbilt University years diagnosed with dHTX after rib fractures at two traumatic hemothorax (dHTX) have not been well Medical Center, Nashville, level 1 trauma centers (March 2018 to September 2019). characterized in literature. The ageing US popula- Tennessee, USA tion and increasing incidence of rib fractures among 4Radiology, Stanford University, dHTX was defined as HTX discovered ≥48 hours after Stanford, California, USA admission chest CT showed either no or ’minimal/trace’ older adults underscore a pressing need for better 5Department of Surgery, HTX. Two blinded, board-certified adiologistsr reviewed understanding.3 This preliminary study examined Vanderbilt University Medical inpatient chest imaging and classified injury patterns older adults with dHTX after suffering rib fractures Center, Nashville, Tennessee, according to Chest Wall Injury Society (CWIS) taxonomy. in- depth to inform future research direction. We USA Descriptive analysis was performed for demographic and hypothesized that dHTX would be infrequent but associated with factors that may aid identification. Correspondence to hospitalization characteristics. copyright. Dr Jeff Choi; jc2226@ stanford. Results We identified 14 patients with pooled edu dHTX rate of 1.3%. After initial chest CT negative METHODS for concerning hemothoraces, the patients did not Study population Received 20 October 2020 undergo follow-up imaging until new symptoms Revised 10 February 2021 We retrospectively reviewed adults aged ≥50 years Accepted 21 February 2021 (shortness of breath, chest pain) developed: eight diagnosed with dHTX after rib fractures at two (57%) were not diagnosed until after discharge from level 1 trauma centers between March 2018 and initial hospitalization (mean (range): 9 (2–20) days after September 2019. We defined dHTX as HTX discov- discharge). Aspirin and/or anticoagulants were involved ered ≥48 hours after admission chest CT showed in fewer than half of cases (43%). According to CWIS either no or ‘minimal/trace’ HTX. We identified taxonomy, all patients had a series of posterolateral patients by querying both centers’ trauma registries fractures with at least one offset or displaced fracture, and electronic medical records for patients aged http://tsaco.bmj.com/ and an average of six consecutive rib fractures. ≥50 years with rib fractures and dHTX diagnosed All patients underwent tube thoracostomy and six during index admission or on readmission. patients (42%)—all aged <65—underwent operative interventions. Discussion Preliminary data suggest older adults with Variables rib fractures may be at risk of experiencing delayed We report patient characteristics (age, sex, body progression of trace hemothoraces or a delayed mass index, smoking status, Charlson Comorbidity presentation of hemothoraces. Asymptomatic progression Index, aspirin/antiplatelet/anticoagulant use within on September 27, 2021 by guest. Protected or readmission to other services/hospitals likely occurs 7 days of injury), injury characteristics (mechanism and true dHTX rates are likely higher. Our preliminary of injury, number of rib fractures, evidence of lung findings suggest a possible anatomic explanation for parenchymal injury), and hospitalization character- severe chest wall injury patterns’ association with istics (hospital length of stay (LOS), interventions, dHTX. Further characterization and capturing the true and readmissions). incidence of dHTX first requires wider recognition of this © Author(s) (or their complication. Detailed characterization of rib fractures employer(s)) 2021. Re- use permitted under CC BY-NC . No Two blinded, board- certified radiologists reviewed commercial re-use . See rights all inpatient chest X- rays and CT scans; every and permissions. Published patient’s imaging was reviewed by one of two by BMJ. INTRODUCTION radiologists. Rib fracture patterns were character- To cite: Choi J, Anand A, The burden of traumatic rib fractures in elderly ized according to Chest Wall Injury Society (CWIS) Sborov KD, et al. Trauma patients is well recognized. Hemothorax (HTX) taxonomy.4 The CWIS taxonomy was established Surg Acute Care Open is a common concomitant injury with rib fractures by an international Delphi consensus panel and 2021;6:e000626. and is usually diagnosed at time of presentation: classifies rib fractures based on displacement Choi J, et al. Trauma Surg Acute Care Open 2021;6:e000626. doi:10.1136/tsaco-2020-000626 1 Open access Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2020-000626 on 8 March 2021. Downloaded from degree (undisplaced, offset (<90% cortical contact), displaced Table 1 Characteristics of patients aged ≥50 years diagnosed (no cortical contact)), fracture type (simple, wedge, complex), with delayed progression of a hemothorax after rib fractures at two neighboring rib fractures (series, not series), and chest wall institutions location (anterior, lateral, posterior, costal). In addition to rib fractures, we also noted radiographic lung injury (chest wall n=14 soft tissue emphysema, pulmonary laceration or contusion, Patient characteristics pneumothorax). Age, mean (SD), years 72.4 (4.0) Male, n (%) 12 (86) Body mass index, mean (SD), kg/m2 26.8 (1.3) RESULTS Charlson Comorbidity Index, mean (SD) 3.3 (1.6) Patient characteristics Medication use within 7 days prior to injury, n (%) We identified 14 older adults who experienced dHTX after rib fractures, with overall dHTX rate of 1.3%. Five patients (36%) ASA 4 (29) had delayed progression of a trace HTX and nine (64%) had Other antiplatelet 1 (7) delayed development of HTX after a negative CT. Mean age Anticoagulant 1 (7) was 72 years and 86% (n=12) were male (table 1). A total of Injury characteristics 57% of patients were not on blood thinning medications within Mechanism of injury, n (%) a week prior to injury; among those who were, aspirin was the Ground- level fall 6 (43) most common medication (n=4, 29%). Patients were placed on Fall from height 3 (21) low molecular weight heparin for inpatient venous thromboem- Motor vehicle crash 2 (14) bolism chemoprophylaxis. All patients aged ≥65 years suffered Bicycle crash 2 (14) ground- level falls, the most common mechanism of injury (n=6, Motorcycle crash 1 (7) 43%), whereas those younger than 65 years experienced higher force injuries. Online supplemental data detail individual patient Injury Severity Score, mean (SD) 13.3 (7.2) characteristics. Number of rib fractures, mean (SD) 6.1 (2.6) Underlying lung injury*, n (%) 6 (43) Initial chest imaging, n (%) Radiographic characteristics No hemothorax 9 (64) All patients underwent chest CT on presentation. Six patients Scant pleural effusion 5 (36) (43%) had underlying lung injury. The average number of copyright. rib fractures was 5.8 and four patients (29%) had flail chest. CWIS taxonomy characterization of rib fractures According to CWIS taxonomy, all patients had a series of frac- Flail chest, n (%) 4 (29) tures, with an average of 5.6 consecutive rib fractures. Only ≥2 consecutive fractures, n (%) 14 (100) three patients had less than four consecutive rib fractures: these Number of consecutive fractures, mean (SD) 5.6 (2.5) patients had two consecutive offset or completely displaced frac- Anterior fractures, n (%) 4 (29) tures. All patients had at least one displaced or offset fracture, Posterolateral fractures, n (%) 14 (100) with an average of 3.5 displaced or offset fractures. All patients Displaced/offset fracture, n (%) 14 (100) had posterolateral fractures and the following fracture pattern Number of displaced/offset fractures, mean (SD) 3.5 (1.9) between the 6th and 10th ribs: a series of posterolateral fractures Wedge or complex fractures, n (%) 7 (50) with at least one offset or displaced fracture. Interventions for delayed hemothorax http://tsaco.bmj.com/ Tube thoracostomy, n (%) 14 (100) Hospitalization characteristics Video- assisted thoracoscopic surgery, n (%) 5 (76) Six patients (43%) were diagnosed with dHTX during initial Thoracotomy, n (%) 1 (17) hospitalization but eight (57%) were not diagnosed
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