Article, Emergency Medicine

Longest delayed hemothorax reported after blunt chest injury

a b s t r a c t

Introduction: Blunt chest injury is a common presentation to the emergency department. However, a delayed hemothorax after blunt trauma is rare; current literature reports a delay of up to 30 days. We present a case of 44-day delay in hemothorax which has not been previously reported in current literature.

Case report: A 52-year-old Caucasian male first presented to the emergency department complaining of persis- tent right sided chest pain 2 weeks after having slipped on a wet surface at home. His initial chest X-ray showed fractures of the right 7th and 8th ribs without a hemothorax or pneumothorax.

He returned 30 days after the initial consultation (44 days post-trauma) having increasing shortness of breath. A chest X-ray this time revealed a large right hemothorax and 1850 ml of blood drained from his chest.

There was a complete resolution of the hemothorax within 48 h and the patient was discharged after a 6-week follow-up with the chest physicians.

Discussion: Delayed hemothorax after blunt trauma is a rare clinical occurrence but associated with significant morbidity and mortality. The management of delayed hemothorax includes draining the hemothorax and controlling the bleeding.

Why should an emergency physician be aware of this?: Emergency physicians should be vigilant and weary that hemothorax could be a possibility after a chest injury despite a delay in presentation. A knowledge of delayed hemothorax will prompt physicians in providing important advice, warning signs and information to patients after a chest injury to avoid a delay in seeking medical attention.

(C) 2017

Introduction

Chest injury after either a Penetrating or blunt trauma is a common presentation to the emergency department but an unrecognized com- plication of traumatic hemothorax is potentially life threatening. Rib fractures from chest trauma are a common in hemothorax cases. Most hemothorax are predicted to be diagnosed at latest 4 days post-incident [1]. A diagnosis of delayed blunt traumatic hemothorax after 44 days is extremely rare and has not been reported in current literature.

Case report

A 52-year-old Caucasian male first presented to the emergency department complaining of persistent right sided chest pain 2 weeks after having slipped on a wet surface at home. He landed onto the edge of a wooden coffee table and sustained a direct blunt thoracic

* Corresponding author at: Department of Otolaryngology, Royal Berkshire Hospital, Craven Rd, Reading RG1 5AN, United Kingdom.

E-mail addresses: [email protected] (D. Yap), [email protected] (M. Chaudhury), [email protected] (N. Mbakada).

trauma over the lateral aspect of his right chest. He had been self- medicating with regular over the counter painkillers with minimal relief. He denied being breathless or having hemoptysis. The pain was aggravated by deep breathing, coughing and lying on the affected side.

He had a past medical history of asthma and lifelong tobacco smoker of 36 pack years. He only drank alcohol in moderation over weekends and worked as a forklift driver in a warehouse. He did not take any anti-coagulant or anti-platelets regularly.

On the initial presentation, his observations showed oxygen satura- tion of 97% on room air with a respiratory rate of 16/min. He was tender over the right chest wall with good bilateral air entry on auscultation. There was no bruising or evidence of flail chest.

His initial chest X-ray showed fractures of the right 7th and 8th ribs

without a hemothorax or pneumothorax as shown in Fig. 1. The patient was discharged with painkillers and chest injury advice leaflet with no further follow-up planned.

Exactly 30 days after the initial consultation (44 days after the day of trauma) the patient returned to the emergency department having trouble sleeping due to increasing shortness of breath. Since his last visit, the pain has been improving until 2 weeks ago when it suddenly got worse. His shortness of breath progressively worsen over the

https://doi.org/10.1016/j.ajem.2017.10.025

0735-6757/(C) 2017

171.e2 D. Yap et al. / American Journal of Emergency Medicine 36 (2018) 171.e1171.e3

Fig. 1. Chest X-ray on initial presentation (14 days post trauma).

week, initially only on exertion, but at time of presentation, the breath- lessness had debilitated him to walking less than 10 yards. He also started feeling generally unwell, having rigors, Loss of appetite, nausea, and vomiting.

On examination, he was alert and orientated, with a low grade fever of 37.6 ?C. He had a pulse rate of 96 beats/min; blood pressure of 132/ 69 mm Hg and oxygen saturation were 94% on room air with a respira- tory rate of 24/min. He had reduced air entry on the right side of his chest and a chest X-ray revealed a large right pleural effusion as shown in Fig. 2. A computerised axial tomography (CT scan) of the tho- rax was performed which reported a large right pleural effusion associ- ated with underlying consolidation and partial collapse of the middle and right lower lobe, lateral rib fractures of the right 7th and 8th ribs as shown in Fig. 3.

Given the history of trauma; we treated this patient as a possibility of delayed hemothorax. ultrasound guided chest drain was inserted which drained 1850 ml of foul smelling blood and samples were sent for cytol- ogy, biochemistry, microscopy, culture and sensitivity.

Fig. 2. Chest X-ray on second presentation (44 days post trauma).

Fig. 3. CT showing 7th rib fracture with hemothorax.

Blood tests showed; WCC 11.6 x 109/l, Neutrophils 9.8 x 109/l, Hb 133 g/l, C-reactive protein 355 mg/l. Coagulation studies, liver and renal function tests were all within normal ranges.

He was started on antibiotics (co-amoxiclav 1 g; intravenous; three times a day) recommended by the hospital pharmacology formulary for a possible empyema and admitted into hospital for observation. Chest fluid biochemistry showed pH 7.42, LDH 3675 iu/l, amylase 47 iu/l, glucose 5.4 mmol/l, protein 48 g/l and albumin 25 g/l. Cytology was reported as a pauci-cellular sample showing scattered lymphocytes, some macrophages and a few mesothelial cells. malignant cells were not seen in this sample. Microbiology reported no organisms seen and blood culture revealed no growth after 48 h.

A repeat chest X-ray performed 48 h after the chest drain insertion showed a complete resolution of the hemothorax. The drain was removed and the patient’s symptoms improved dramatically. He was discharged home with oral antibiotics (Amoxicillin 500 mg; three time a day for 7 days) and follow-up appointment with the chest physi- cians in 6 weeks.

At the follow-up clinic, a repeat CT thorax showed complete resolu- tion of the effusion and non-union of the 7th and 8th fractured ribs. His breathing was back to normal with occasional mild pain over the non- united rib fractures. At that point he was discharged with no further hospital appointments and advised to follow up with his own family doctor if he developed any problems.

Discussion

Hemothorax is defined as the collection of blood within the pleural space triggered by either a blunt or penetrating trauma. Delayed hemothorax following a blunt chest injury is a rare attendance in the emergency department. It is defined as hemothorax which appears 24 h or later after injury [2]. Ritter et al. modified the definition of de- layed hemothorax as clinical investigations confirming a hemothorax on the second investigation and absent on the first with the time gap between the two investigations being as little as 2 h [3].

The most common cause of delayed hemothorax is motor vehicle ac- cident and pedestrian accidents (80.9%) [4,5]. To our knowledge, a large hemothorax diagnosed 44 days post trauma has never been reported within the literature as shown in Table 1. According to Sharma et al.,

D. Yap et al. / American Journal of Emergency Medicine 36 (2018) 171.e1171.e3 171.e3

Table 1

Case reports on delayed hemothoraces [5-12].

No.

Author

Year

Age

Gender

Duration of delay

1

Blair et al.

1971

n/a

n/a

n/a

2

Symbas

1978

n/a

n/a

n/a

3

Simon et al.

1998

Case series

12 patients

18 h-6 days

4

Misthos et al.

2004

Case series

52 patients

2-14 days

5

Masuda et al.

2013

56

Male

30 days

6

Chen et al.

2014

60

Male

6 days

7

Ahn et al.

2016

24

Female

13 days

8

Yap et al.

2017

52

Male

44 days

hemothorax injury post chest trauma can present as early as 6 h after the incident up to and including 30 days after the injury [1]. On their re- view, the average time between chest injury and Delayed presentation is 4 days. Literatures suggest that delayed hemothorax are found in patients with blunt trauma between 2.1% and 33% [2,5,7].

One common key clinical finding in all cases was having at least one rib fracture [5]. It has been reported that 92% of delayed hemothorax has evidence of either multiple rib fractures or solitary displaced fracture [4, 6]. This finding was similar in our case with right lateral 7th and 8th rib fracture. A fractured rib from a blunt trauma can also cause sternal fracture or laceration to the diaphragm; presenting as a mixture of chest pain and worsening shortness of breath [7].

Chest X-ray is the recommended investigation as it can be easily conducted and cost-effective [5]. CT scan could provide more detailed images and underlying structural abnormalities. Chest X-ray and CT scan are helpful in patients who are hemodynamically stable. Portable ultrasonography is highly sensitive and specific in identifying fluid accu- mulation in internal cavities under the hands of qualified practitioners; and it is advantageous over the other modalities in hemodynamically unstable patients.

Management of delayed hemothorax is controlling the bleeding and evacuating the collected blood found within the Pleural cavity. Once hemodynamic stability is established, a tube thoracoscopy is conducted as it involves minimal invasion. Thoracotomy is more invasive and only performed when a patient is hemodynamically unstable [8].

Current literature suggests that if a patient does not fulfil the criteria for in-hospital management after a blunt chest trauma; they should still be observed in an outpatient setting for a minimum of 14 days post incident, especially if fracture of the lower ribs are noted [5]. The follow- up management includes a clinical and radiological check-up in 2 weeks [5]. This is for any anticipated delayed hemothorax allowing excellent prognosis if diagnosed promptly.

Finally, whilst coagulation abnormalities and thoracic rib fractures are not known to have a uniform relationship; it is necessary to restrict patient’s Alcohol intake for weeks post blunt injury to reduce the peripheral vessel dilator effects of alcohol on bleeding.

Clinical presentation of pleuritic chest pain and significant dyspnea post trauma is virtually a confirmation of the presence of hemothorax. However in patients who have suspected delayed hemothorax but fail to exhibit any sign of pleural effusion on chest X-ray or do not improve after drainage, they should be investigated for a possibility of pulmo- nary embolism. Both these conditions have similar clinical presentation [6,9].

Why should an emergency physician be aware of this?

Blunt trauma delayed hemothoraces have been associated with sig- nificant morbidity [6]. Delayed hemothorax is thought to be associated with chest physiotherapy, violent coughing or change in position;

which could occur after initial consultation at the emergency department [12]. As an emergency physician, it is important to have a high index of suspicion of delayed hemothorax after a blunt injury as delayed or misdi- agnosis can be potentially fatal for the patient. Every patient presented to the emergency department with a blunt chest injury should be educated and given sufficient information about this pathology. Physicians can provide a patient information leaflet emphasizing important worrying signs and symptoms or offer a follow-up appointment for the patient to avoid a Delay in diagnosis.

Ethics approval

Not applicable.

Competing interests

The author(s) declare that they have no competing interests.

Authors’ contributions

“All authors wrote, edited, read and approved the final manuscript.”

Acknowledgement

Not applicable.

Funding

No funding obtained from external sources.

Consent

Non-identifiable images.

Formal consents are not required for the use of entirely anonymised images from which the individual cannot be identified- for example, X-rays, ultrasound images, pathology slides or laparoscopic images, provided that these do not contain any identifying marks and are not accompanied by text that might identify the individual concerned.

References

  1. Sharma OP, Hagler S, Oswanski M. Prevalence of delayed hemothorax in blunt tho- racic trauma. Am Surg 2005;71:481-6.
  2. Shorr R, Crittenden M, Indeck M, et al. Blunt Thoracic trauma analysis of 515 patients.

    Ann Surg 1987;206(2):200-5.

    Ritter D, Chang F. Delayed hemothorax resulting from Stab wounds to the internal mammary artery. J Trauma 1995;39:586-9.

  3. Lu M, Huang Y, Liu Y, et al. Delayed pneumothorax complicating minor rib fracture after chest trauma. Am J Emerg Med 2008;26(5):551-4.
  4. Misthos P, Kakaris S, Sepsas, et al. A Prospective analysis of Occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. Eur J Cardiothorac Surg 2004;25(5):859-64.
  5. Simon B, Chu Q, Emhoff T, et al. Delayed Hemothorax after Blunt Thoracic Trauma. The Journal of Trauma: Injury, Infection, and Critical Care 1998;45(4):673-6.
  6. Masuda R, Ikoma Y, Oiwa K, et al. Delayed hemothorax superimposed on extrapleural hematoma after blunt chest injury: a case report. Tokai J Exp Clin Med 2013;38(3):97-102.
  7. Chen C, Cheng Y. Delayed massive hemothorax complicating simple rib fracture as- sociated with diaphragmatic injury. Am J Emerg Med 2014;32(7):818.e3-4.
  8. Palla A, Petruzzelli S, Donnamaria V, et al. The role of suspicion in the diagnosis of pulmonary embolism. Chest 1995;107(1):21S-4S.
  9. Symbas P. Acute traumatic hemothorax. Ann Thorac Surg 1978;26(3):195-6.
  10. Blair E, Topuzlu C, Davis J. Delayed or missed diagnosis in blunt chest trauma. J Trau-

    ma 1971;11(2):129-45.

    Ahn H, Lee J, Kim K, et al. Phrenic arterial injury presenting as delayed hemothorax complicating simple rib fracture. J Korean Med Sci 2016;31:641-3.

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