Clin Exp Emerg Med 2018;5(1):60-65 https://doi.org/10.15441/ceem.16.190 Case Report Delayed massive hemothorax requiring eISSN: 2383-4625 surgery after blunt thoracic trauma over a 5-year period: complicating rib fracture with sharp edge associated with diaphragm injury Received: 26 September 2017 Revised: 28 January 2018 Sung Wook Chang, Kyoung Min Ryu, Jae-Wook Ryu Accepted: 20 February 2018 Trauma Center, Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Cheonan, Korea Correspondence to: Jae-Wook Ryu Department of Thoracic and Cardiovascular Surgery, Dankook Delayed massive hemothorax requiring surgery is relatively uncommon and can potentially be University Hospital, 201 Manghyang-ro, Dongnam-gu, Cheonan 31116, Korea life-threatening. Here, we aimed to describe the nature and cause of delayed massive hemotho- E-mail: [email protected] rax requiring immediate surgery. Over 5 years, 1,278 consecutive patients were admitted after blunt trauma. Delayed hemothorax is defined as presenting with a follow-up chest radiograph and computed tomography showing blunting or effusion. A massive hemothorax is defined as blood drainage >1,500 mL after closed thoracostomy and continuous bleeding at 200 mL/hr for at least four hours. Five patients were identified all requiring emergency surgery. Delayed mas- sive hemothorax presented 63.6±21.3 hours after blunt chest trauma. All patients had superfi- cial diaphragmatic lacerations caused by the sharp edge of a broken rib. The mean preoperative chest tube drainage was 3,126±463 mL. We emphasize the high-risk of massive hemothorax in patients who have a broken rib with sharp edges. Keywords Thoracic injuries; Hemothorax; Diaphragm; Rib fractures What is already known Thoracic trauma is a leading cause of mortality, and massive hemothorax is one How to cite this article: of the major causes. Generally, massive hemothorax is commonly observed at Chang SW, Ryu KM, Ryu JW. Delayed admission or immediately after trauma. In most cases, massive intrathoracic massive hemothorax requiring surgery after bleeding is the main indicator for immediate surgery, whereas a retained hemo- blunt thoracic trauma over a 5-year period: thorax or minor diaphragmatic injuries are indicators for delayed surgery. There- complicating rib fracture with sharp edge fore, delayed massive hemothorax requiring emergency surgery is relatively un- associated with diaphragm injury. Clin Exp Emerg Med 2018;5(1):60-65. common, although it can be potentially life-threatening. What is new in the current study This is an Open Access article distributed The purpose of this study is to describe the nature of delayed massive hemotho- under the terms of the Creative Commons rax requiring immediate surgery and to identify the major cause. Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/). 60 Copyright © 2018 The Korean Society of Emergency Medicine Sung Wook Chang, et al. INTRODUCTION ture, and is commonly observed at admission or immediately af- ter trauma.1,2 Delayed hemothorax can be caused by a diaphragm Thoracic trauma is a leading cause of morbidity and mortality, injury or bone bleeding from a fractured rib and is observed after and massive hemothorax is one of the major causes.1 Generally, a certain period.3 Treatment decisions, such as surgery versus con- massive hemothorax is caused by injury to the intercostal artery, servative management, depend on the correct evaluation of the laceration of the lung, great vessel injury, or diaphragmatic rup- patient symptoms.1,3 In most cases, massive intrathoracic bleed- A B C D Fig. 1. Chest computed tomography (CT) after blunt thoracic trauma showing a fractured rib with a sharp edge (arrows). (A) Patient 1. De- layed hemothorax and extravasation seen 93 hours after the initial CT. (B) Patient 2. CT showing only a fractured rib with no hemothorax 7 hours later. (C) Patient 3. Delayed hemothorax seen 66 hours later. (D) Patient 4. Delayed hemothorax and extravasation seen 63 hours after the initial CT. (E) Patient 5. CT showing left hemothorax and periaortic E hematoma 2 hours later. Clin Exp Emerg Med 2018;5(1):60-65 61 mediate surgeryandtoidentifyitsmajorcause. describe thenatureofdelayedmassivehemothoraxrequiringim tentially belife-threatening. emergency surgeryisrelativelyuncommon,althoughitcanpo Therefore,delayedmassivehemothoraxrequiring delayed surgery. ed hemothoraxorminordiaphragmaticinjuriesareindicatorsfor retain a whereas surgery, immediate for indicator main the is ing mL/hr foratleastfourhours.Thedatawerepresentedasmean closed thoracostomyandcontinuousbleedingattherateof200 hemothoraxisdefinedasblooddrainage sive >1,500 mLafter Mas and nopleuraleffusionhadbeendetected byachestCT. ing mediately afterthetraumadidnotshowcostophrenicangleblunt at admissionorim normal uprightchestradiograph performed puted tomography(CT)showingbluntingoreffusionforwhicha fined aspresentingwithafollow-upchestradiographandcom quired operationduetohemothorax.Delayedhemothoraxisde ted toourhospitalafterbluntthoracictrauma,25ofwhichre 1,278patientswereadmit toJanuary2015, From February2011 CASE REPORTS 62 book. 2008hand the AIS calculated using was manually The ISS update. ated injuryscore(AIS)andseverity(ISS)followingthe associatedinjurieswererecordedaccordingtotheabbrevi Their trauma orhadretainedhemothoraxwereexcludedfromthestudy. to acutemassivehemothoraxoccurringimmediatelyafterthe patientswhowereoperatedondue standard deviation.Twenty ter theprocedure.Delayedmassivehemothoraxpresented at63.6 Amongthem,three werehemodynamicallyunstableaf hospital. hemothorax. Fourpatientsunderwentclosedthoracostomyatour ISS was22 the knee.AchestCTwasperformedforeachpatient(Fig.1).The laceration on a deep lacerations, and fracture, liver pelvic bone ture withliverandscalplacerations;oneaorticdissection, extrathoracic injuries:onetibiofibularfracture;claviclefrac dent, anddrivertrafficaccident.Threepatientshadconcurrent acci traffic pedestrian accident, motorcycle slipping, falling, ly, ter name trauma. Eachpatienthadadifferentmechanismofinjury, ent hospitalandtwopresentedatouremergencydepartmentaf pain withdyspnea.Threepatientsweretransferredfromadiffer admitted toourhospital.Allpatientsweremenandhadchest (range, 2,700 to 3,730 mL). Before surgery, allpatientshadanacute- (range, to3,730 mL). Beforesurgery, 2,700 was 3,126 tube drainage preoperative chest The mean hours (range,33to93hours)afterbluntthoracictrauma. 21.3 Three patients had right hemothorax and two patients hadleft right hemothoraxand two Three patientshad A totaloffivepatientswithdelayedmassivehemothoraxwere 7 ± 7.1 (range,16to33). 2,4-6 The purpose of this study is to Thepurposeofthisstudyisto ± 463 mL ± ± - - - - - - - - - - - - - - - - - - Table 1. Clinical characteristics and outcomes Preoperative Time from Transferred Blood pressure Fractured ICU Case Age Additional injuries LOS Sex Cause ISS Side chest tube injury to from other (mmHg) after imme- Operation MRF rib with LOS no. (yr) besides thorax (day) drainage (mL) diagnosis (hr) hospital diate thoracostomy sharp edge (day) 1 52 M Fall No 16 Left 2,750 93 Yes NA Open thoracotomy Left 4th–10th Left 8th 8 1 Delayed massivehemothoraxrequiringsurgery After closed thoracostomy 2 44 M Slip No 16 Right 2,950 63 Yes 111/62 VATS followed by Right 8th–10th Right 10th 12 3 thoracotomy Left 10th 3 45 M Motorcycle Tibiofibula Fx 20 Left 2,700 66 Yes 76/52 Open thoracotomy Left 10th–12th Left 11th 88 2 Rib fixation 4 59 M Pedestrian Clavicle Fx 24 Right 3,500 63 No 83/50 Open thoracotomy Right 1st–11th Right 7th 31 6 traffic Liver laceration Rib fixation Left 1st–2nd accident Scalp laceration www.ceemjournal.org www.ceemjournal.org 5 31 M Driver traffic Aortic dissection 33 Right 3,730 33 No 75/30 VATS followed by Right 3rd–8th Right 6th 42 11 accident Pelvic bone Fx thoracotomy Left 4th–7th Liver laceration Deep laceration on the knee ISS, injury severity score; MRF, multiple rib fracture; LOS, length of stay; ICU, intensive care unit; NA, not available; VATS, video-assisted thoracic surgery; Fx, fracture. Sung Wook Chang, et al. A B Fig. 2. Patient 5. (A) Computed tomography showing an aortic dissection without right hemothorax. (B) Follow- up chest radiograph after thoracic endovascular aortic repair showing massive right hemothorax. (C) Intraoper- ative photograph showing active bleeding on the dia- C phragm due to superficial injury (arrow). onset, aggravated chest pain with cold sweats after a coughing DISCUSSION spell. The patients’ clinical characteristics are shown in Table 1. We performed emergency open thoracotomy in three patients Hemothorax can be categorized into two conditions by a time and video-assisted thoracic surgery (VATS) followed by a thoracot- sequence. At the time of admission or immediately after trauma, omy in two patients. One patient underwent thoracic endovascu- patients with costophrenic angle blunting observed on an upright lar aortic repair due to traumatic aortic dissection using heparin chest radiograph or effusion observed on CT are classified as cas- (intravenous 3,000 IU bolus). In this case, the patient was con- es of acute hemothorax. Conversely, cases without blunting or firmed as having delayed massive hemothorax on the right side effusion on the initial radiograph or CT are classified as cases of 16 hours after thoracic endovascular aortic repair (Fig. 2). delayed hemothorax. According to the literature, the prevalence All patients had superficial lacerations on the diaphragm with- of delayed