RESUMO
BACKGROUND: Traumatic hemothorax (HTX) is common, and while it is recommended to drain it with a tube thoracostomy, there is no consensus on the optimal catheter size. We performed a systematic review to test the hypothesis that small bore tube thoracostomy (SBTT) (≤14 F) is as effective as large-bore tube thoracostomy (LBTT) (≥20F) for the treatment of HTX. METHODS: Pubmed, EMBASE, Scopus, and Cochrane review were searched from inception to November 2022 for randomized controlled trials or cohort studies that included adult trauma patients with HTX who received a tube thoracostomy. Data was extracted and Critical Appraisal Skills Program checklists were used for study appraisal. The primary outcome was failure rate, defined as incompletely drained or retained HTX requiring a second intervention. Cumulative analysis was performed with χ 2 test for dichotomous variables and an unpaired t-test for continuous variables. Meta-analysis was performed using a random effects model. RESULTS: There were 2,008 articles screened, of which nine were included in the analysis. The studies included 1,847 patients (714 SBTT and 1,233 LBTT). The mean age of patients was 46 years, 75% were male, average ISS was 20, and 81% had blunt trauma. Failure rate was not significantly different between SBTT (17.8%) and LBTT (21.5%) ( p = 0.166). Additionally, there were no significant differences between SBTT vs. LBTT in mortality (2.9% vs. 6.1%, p = 0.062) or complication rate (12.3% vs. 12.5%, p = 0.941), however SBTT had significantly higher initial drainage volumes (753 vs. 398 mL, p < 0.001) and fewer tube days (4.3 vs. 6.2, p < 0.001). There are several limitations. Some studies did not report all the outcomes of interest, and many of the studies are subject to selection bias. CONCLUSION: SBTT may be as effective as LBTT for the treatment of traumatic HTX. LEVEL OF EVIDENCE: Systematic Review/Meta-Analysis; Level IV.
Assuntos
Tubos Torácicos , Hemotórax , Traumatismos Torácicos , Toracostomia , Humanos , Hemotórax/etiologia , Hemotórax/cirurgia , Hemotórax/terapia , Toracostomia/métodos , Toracostomia/instrumentação , Traumatismos Torácicos/complicações , Traumatismos Torácicos/cirurgia , Drenagem/métodos , Drenagem/instrumentaçãoRESUMO
Bleeding within the pleural space may result in persistent clot formation called retained hemothorax (RH). RH is prone to organization, which compromises effective drainage, leading to lung restriction and dyspnea. Intrapleural fibrinolytic therapy is used to clear the persistent organizing clot in lieu of surgery, but fibrinolysin selection, delivery strategies, and dosing have yet to be identified. We used a recently established rabbit model of RH to test whether intrapleural delivery of single-chain urokinase (scuPA) can most effectively clear RH. scuPA, or single-chain tissue plasminogen activator (sctPA), was delivered via thoracostomy tube on day 7 as either one or two doses 8 h apart. Pleural clot dissolution was assessed using transthoracic ultrasonography, chest computed tomography, two-dimensional and clot displacement measurements, and gross analysis. Two doses of scuPA (1 mg/kg) were more effective than a bolus dose of 2 mg/kg in resolving RH and facilitating drainage of pleural fluids (PF). Red blood cell counts in the PF of scuPA, or sctPA-treated rabbits were comparable, and no gross intrapleural hemorrhage was observed. Both fibrinolysins were equally effective in clearing clots and promoting pleural drainage. Biomarkers of inflammation and organization were likewise comparable in PF from both groups. The findings suggest that single-agent therapy may be effective in clearing RH; however, the clinical advantage of intrapleural scuPA remains to be established by future clinical trials.
Assuntos
Fibrinolíticos , Hemotórax , Terapia Trombolítica , Ativador de Plasminogênio Tecidual , Ativador de Plasminogênio Tipo Uroquinase , Animais , Coelhos , Hemotórax/etiologia , Hemotórax/terapia , Ativador de Plasminogênio Tipo Uroquinase/metabolismo , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/uso terapêutico , Fibrinolíticos/administração & dosagem , Fibrinolíticos/farmacologia , Fibrinolíticos/uso terapêutico , Terapia Trombolítica/métodos , Modelos Animais de Doenças , Pleura/efeitos dos fármacosRESUMO
RATIONALE: Subclavian arterial injury due to blunt trauma is rare but can have devastating outcomes. Massive hemorrhage or limb ischemia might develop depending on the extent of damage, and open repair might be necessary to salvage the limb. However, life-saving treatments should be prioritized in critically unstable patients. PATIENT CONCERNS: A 21-year-old male patient who was transferred to our trauma center following a motorcycle accident. Abdominal and chest computed tomography (CT) revealed right renal injury and massive hemothorax with several rib fractures in the right chest. DIAGNOSIS AND INTERVENTIONS: Right renal injury with multiple extravasations and right 8th intercostal arterial injury were detected during angiography. Emergent exploration with lateral thoracotomy was performed to manage right hemothorax. Pulsating bleeding from the thoracic roof observed in the operative field suggested a subclavian arterial injury. The unstable vital signs did not recover despite massive transfusion, and his right arm had already stiffened. Therefore, endovascular approach was adopted and the second portion of the right subclavian artery was embolized using microcoils and thrombin. OUTCOMES: Postoperative intensive care unit management performed to resuscitate patient from multiorgan failure included continuous renal replacement therapy (CRRT). After confirming the demarcation lines, transhumeral amputation of the right arm was performed on admission day 12. The patient recovered from multiorgan failure for more than 3 weeks after the accident; however, the patient survived. LESSONS: Limb salvage, albeit critical for quality of life, is not possible in some cases where life-saving measures require its sacrifice. In these cases, quick decision-making by the surgeon is paramount for patient survival. As illustrated in this case, endovascular approaches should be considered less invasive measures to save the patient's life.
Assuntos
Artéria Subclávia , Ferimentos não Penetrantes , Humanos , Masculino , Artéria Subclávia/lesões , Artéria Subclávia/cirurgia , Ferimentos não Penetrantes/complicações , Adulto Jovem , Acidentes de Trânsito , Ruptura/cirurgia , Hemotórax/etiologia , Hemotórax/cirurgia , Embolização Terapêutica/métodos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: The objective of this study was to describe the causes of haemothorax in cats, patient presentation and outcome. METHODS: This was a retrospective study based in a university teaching hospital. The electronic case records of cats presenting with a haemothorax between January 2005 and January 2023 were searched. Cases were categorised into 'trauma', 'neoplasia', 'coagulopathy' or 'other'. Signalment, physical examination, clinical pathology findings, concurrent injuries and diagnostic imaging findings were recorded. The median hospitalisation time was calculated, and survival to discharge was noted. RESULTS: Twenty-five cats were eligible for inclusion. Twenty cases of haemothorax were traumatic in origin, two were neoplastic, two were 'other' and one was coagulopathic. Increased respiratory rate (n = 22) and effort (n = 20) were common, and most patients were anaemic at presentation (n = 16). Common concurrent injuries included pulmonary contusions (n = 15) and pneumothorax (n = 11). The median hospitalisation time for the trauma cats was 5 days (range 1â15). Overall, 83.3% of the cases survived to discharge. LIMITATIONS: The limitations of this study are related to its retrospective nature and the relatively small number of cats in the study population. CONCLUSION: Haemothorax requiring a thoracocentesis in cats is rare, with trauma being the most likely cause. These patients tend to have concurrent injuries and require ongoing hospitalisation. Owners can be advised that the short-term outcome is generally favourable.
Assuntos
Doenças do Gato , Hemotórax , Animais , Gatos , Estudos Retrospectivos , Masculino , Feminino , Hemotórax/veterinária , Hemotórax/etiologiaRESUMO
BACKGROUND: Penetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure. CASE DESCRIPTION: A male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery. CONCLUSIONS: Penetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients.
Assuntos
Oxigenação por Membrana Extracorpórea , Pneumonectomia , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Masculino , Lesão Pulmonar/cirurgia , Lesão Pulmonar/etiologia , Adulto , Traumatismos Torácicos/cirurgia , Traumatismos Torácicos/complicações , Ferimentos Penetrantes/cirurgia , Hemotórax/etiologia , Hemotórax/cirurgia , Cuidados Pós-Operatórios/métodosRESUMO
PURPOSE: Post-operative pain after video-assisted thoracoscopic surgery is often treated using thoracic epidural analgesics or thoracic paravertebral analgesics. This article describes a case where a thoracic disc herniation is treated with a thoracoscopic microdiscectomy with post-operative thoracic epidural analgesics. The patient developed a bupivacaine pleural effusion which mimicked a hemothorax on computed tomography (CT). METHODS: The presence of bupivacaine in the pleural effusion was confirmed using a high performance liquid chromatography method. RESULTS: The patient underwent a re-exploration to relieve the pleural effusion. The patient showed a long-term recovery similar to what can be expected from an uncomplicated thoracoscopic microdiscectomy. CONCLUSION: A pleural effusion may occur when thoracic epidural analgesics are used in patents with a corridor between the pleural cavity and epidural space.
Assuntos
Anestesia Epidural , Bupivacaína , Discotomia , Hemotórax , Deslocamento do Disco Intervertebral , Derrame Pleural , Humanos , Anestesia Epidural/efeitos adversos , Anestesia Epidural/métodos , Discotomia/efeitos adversos , Discotomia/métodos , Bupivacaína/efeitos adversos , Deslocamento do Disco Intervertebral/cirurgia , Derrame Pleural/diagnóstico por imagem , Derrame Pleural/cirurgia , Hemotórax/etiologia , Hemotórax/cirurgia , Hemotórax/induzido quimicamente , Hemotórax/diagnóstico , Hemotórax/diagnóstico por imagem , Cirurgia Torácica Vídeoassistida/métodos , Cirurgia Torácica Vídeoassistida/efeitos adversos , Diagnóstico Diferencial , Anestésicos Locais/efeitos adversos , Anestésicos Locais/administração & dosagem , Vértebras Torácicas/cirurgia , Masculino , Dor Pós-Operatória/tratamento farmacológico , Pessoa de Meia-Idade , FemininoRESUMO
OBJECTIVE: The mini-open lateral retropleural (MO-LRP) approach is an effective option for surgically treating thoracic disc herniations, but the approach raises concerns for pneumothorax (PTX). However, chest tube placement causes insertion site tenderness, necessitates consultation services, increases radiation exposure (requires multiple radiographs), delays the progression of care, and increases narcotic requirements. This study examined the incidence of radiographic and clinically significant PTX and hemothorax (HTX) after the MO-LRP approach, without the placement of a prophylactic chest tube, for thoracic disc herniation. METHODS: This study was a single-institution retrospective evaluation of consecutive cases from 2017 to 2022. Electronic medical records were reviewed, including postoperative chest radiographs, radiology and operative reports, and postoperative notes. The presence of PTX or HTX was determined on chest radiographs obtained in all patients immediately after surgery, with interval radiographs if either was present. The size was categorized as large (≥ 3 cm) or small (< 3 cm) based on guidelines of the American College of Chest Physicians. PTX or HTX was considered clinically significant if it required intervention. RESULTS: Thirty patients underwent thoracic discectomy via the MO-LRP approach. All patients were included. Twenty patients were men (67%), and 10 (33%) were women. The patients ranged in age from 25 to 74 years. The most commonly treated level was T11-12 (n = 11, 37%). Intraoperative violation of parietal pleura occurred in 5 patients (17%). No patient had prophylactic chest tube placement. Fifteen patients (50%) had PTX on postoperative chest radiographs; 2 patients had large PTXs, and 13 had small PTXs. Both patients with large PTXs had expansion on repeat radiographs and were treated with chest tube insertion. Of the 13 patients with a small PTX, 1 required 100% oxygen using a nonrebreather mask; the remainder were asymptomatic. One patient, who had no abnormal findings on the immediate postoperative chest radiograph, developed an incidental HTX on postoperative day 6 and was treated with chest tube insertion. Thus, 3 patients (10%) required a chest tube: 2 for expanding PTX and 1 for delayed HTX. CONCLUSIONS: Most patients who undergo thoracic discectomy via the MO-LRP approach do not develop clinically significant PTX or HTX. PTX and HTX in this patient population should be treated with a chest tube only when there are postoperative clinical and radiographic indications.
Assuntos
Tubos Torácicos , Discotomia , Hemotórax , Deslocamento do Disco Intervertebral , Pneumotórax , Complicações Pós-Operatórias , Vértebras Torácicas , Humanos , Pneumotórax/etiologia , Pneumotórax/diagnóstico por imagem , Pneumotórax/prevenção & controle , Masculino , Feminino , Pessoa de Meia-Idade , Hemotórax/etiologia , Hemotórax/cirurgia , Hemotórax/diagnóstico por imagem , Hemotórax/prevenção & controle , Discotomia/efeitos adversos , Discotomia/métodos , Vértebras Torácicas/cirurgia , Vértebras Torácicas/diagnóstico por imagem , Estudos Retrospectivos , Adulto , Incidência , Deslocamento do Disco Intervertebral/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/diagnóstico por imagem , IdosoRESUMO
As one of a major public health issue in China, the number of new cases and deaths of malignant tumors has been climbing year by year. Implantable venous access port (IVAP) is used as a safe infusion route in the treatment of malignant tumor patients such as infusion of antitumor drugs and intravenous nutrition. With the widespread application of ultrasound-guided Sedinger puncture techniques and intracardiac electrocardiogram positioning technology, IVAP in the upper arm has been recognized by the majority of medical personnel and cancer patients due to its advantages of hiding scars and completely avoiding the risk of hemothorax and pneumothorax. In order to standardize the clinical application of IVAP via the upper arm approach in cancer patients, improve the success rate of implantation, reduce complications and improve patient satisfaction, the Breast Cancer Expert Committee of the National Cancer Quality Control Center consulted guidelines and the latest evidence-based evidences and established the expert consensus on the whole-course management of implantable venous access port in the upper arm of cancer patients through literature research and expert discussions, in order to provide reference for the standard application of IVAP in the upper arm. The consensus mainly introduces the indications, contraindications, preoperative evaluation, implantation site, operation procedure, utilization and maintenance, complications and management, medical staff training and patient education of IVAP in the upper arm, in order to provide reference for clinical staff.
Assuntos
Braço , Cateteres de Demora , Neoplasias , Humanos , Braço/irrigação sanguínea , Antineoplásicos/administração & dosagem , Cateterismo Venoso Central/métodos , Cateterismo Venoso Central/efeitos adversos , Consenso , China , Pneumotórax/etiologia , Hemotórax/etiologia , Neoplasias da MamaRESUMO
BACKGROUND: Late hemothorax is a rare complication of blunt chest trauma. The longest reported time interval between the traumatic event and the development of hemothorax is 44 days. CASE PRESENTATION: An elderly patient with right-sided rib fractures from chest trauma, managed initially with closed thoracostomy, presented with a delayed hemothorax that occurred 60 days after initial management, necessitating conservative and then surgical intervention due to the patient's frail condition and associated complications. CONCLUSIONS: This case emphasizes the clinical challenge and significance of delayed hemothorax in chest trauma, highlighting the need for vigilance and potential surgical correction in complex presentations, especially in the elderly.
Assuntos
Hemotórax , Fraturas das Costelas , Traumatismos Torácicos , Ferimentos não Penetrantes , Humanos , Hemotórax/etiologia , Hemotórax/cirurgia , Ferimentos não Penetrantes/complicações , Traumatismos Torácicos/complicações , Fraturas das Costelas/complicações , Fraturas das Costelas/cirurgia , Masculino , Toracostomia , Fatores de Tempo , Idoso de 80 Anos ou mais , Tomografia Computadorizada por Raios X , IdosoRESUMO
BACKGROUND: Pulmonary arteriovenous malformation (PAVM), also known as pulmonary arteriovenous fistula, is a rare vascular developmental anomaly. Most cases of PAVM are associated with hereditary hemorrhagic telangiectasia (HHT). Hemothorax associated with PAVM is even rarer, and management concerning this complication still challenges. CASE PRESENTATION: A 55-year-old man with sudden onset of dyspnea and chest pain was admitted to our hospital. He had a medical history of epistaxis, intraperitoneal germ cell tumor and PAVM. Chest unenhanced CT revealed the left-sided pleural effusion together with partial passive atelectasis and gradual increase at the interval of six days. Diagnostic thoracocentesis further revealed hemorrhagic effusion. CT angiography (CTA) showed tortuously dilated lumen of the left lower pulmonary artery and PAVM with the formation of aneurysm. Due to his family's refusal of surgery, the patient underwent transcatheter embolization therapy. However, the left pleural effusion did not significantly reduce and there was a slow drop in hemoglobin value even after interventional treatment, indicating the possibility of ongoing active bleeding. Eventually, the patient received lobectomy of the left lower lobe with a satisfactory outcome. CONCLUSIONS: Massive hemothorax resulting from PAVM rupture into the pleural space can lead to fatal outcomes. CTA can accurately diagnose this pathologic condition. Transcatheter embolization is frequently used in the treatment of PAVM, but it may be challenging to achieve the desirable effect in patients with hemothorax. Combined with our case and literature review, direct radical surgery can lead to a successful outcome when PAVM complicated with hemothorax and a large diameter of the draining vein.
Assuntos
Fístula Arteriovenosa , Hemotórax , Artéria Pulmonar , Veias Pulmonares , Humanos , Hemotórax/etiologia , Masculino , Pessoa de Meia-Idade , Artéria Pulmonar/anormalidades , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/cirurgia , Veias Pulmonares/anormalidades , Fístula Arteriovenosa/complicações , Fístula Arteriovenosa/cirurgia , Malformações Arteriovenosas/complicações , Angiografia por Tomografia Computadorizada , Embolização Terapêutica/métodos , Ruptura Espontânea/complicações , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Hemorrhage is the most common major complication after liver biopsy. Hemothorax is one type of bleeding and is very rare and dangerous. Several cases of hemothorax subsequent to liver biopsy have been documented, primarily attributed to injury of the intercostal artery or inferior phrenic artery and a few resulting from lung tissue damage; however, no previous case report of hemothorax caused by injury of musculophrenic artery after liver biopsy has been reported. CASE PRESENTATION: A 45-year-old native Chinese woman diagnosed with primary biliary cirrhosis due to long-term redness in urination and abnormal blood test indicators was admitted to our hospital for an ultrasound-guided liver biopsy to clarify pathological characteristics and disease staging. A total of 2 hours after surgery, the patient complained of discomfort in the right chest and abdomen. Ultrasound revealed an effusion in the right thorax and hemothorax was strongly suspected. The patient was immediately referred to the interventional department for digital subtraction angiography. Super-selective angiography of the right internal thoracic artery was performed which revealed significant contrast medium extravasation from the right musculophrenic artery, the terminal branch of the internal thoracic artery. Embolization was performed successfully. The vital signs of the patient were stabilized after the transarterial embolization and supportive treatment. CONCLUSION: This case draws attention to the musculophrenic artery as a potential source of hemorrhage after percutaneous liver biopsy.
Assuntos
Embolização Terapêutica , Hemotórax , Fígado , Humanos , Hemotórax/etiologia , Feminino , Pessoa de Meia-Idade , Fígado/patologia , Fígado/diagnóstico por imagem , Fígado/irrigação sanguínea , Ultrassonografia de Intervenção , Biópsia Guiada por Imagem/efeitos adversos , Angiografia DigitalRESUMO
BACKGROUND: Unlike large hemothoraces (HTX), small HTX after blunt trauma may be observed without drainage. We aimed to study if there were risk factors that would predict the need for intervention in initially observed small HTX. METHODS: A retrospective review of patients with blunt traumatic HTX from 2016 to 2022 was performed. Patients with small HTX (pleural fluid volume <400 mL on admission chest computerized tomography [CT]) were included. Patients were considered as being "initially observed" if there was no intervention for the HTX within 48 hours after admission. Primary outcome was any HTX-related intervention (open, thoracoscopic or percutaneous procedures) occurring after 48 hours and up to 6 months after injury. Univariable and multivariable statistical analyses were employed. A P-value of <.05 was considered significant. RESULTS: Of 335 patients with HTX, 188 (59.6%) met inclusion criteria. Median (interquartile range) HTX volume was 90 (36-134) ml. One hundred and twenty-seven (68%) were initially observed. Of these, 31 (24%) had the primary outcome. These patients had a larger HTX volume (median, 129 vs 68 mL, P = .0001), and number of rib fractures (median, 7 vs 4, P = .0002) compared to those without the primary outcome. Chest-related readmission occurred in 8 (6%) with a median of 20 days from injury. Of these, 7 required an HTX-related intervention. Logistic regression analysis found that both the number of rib fractures and HTX volume independently predicted the primary outcome. CONCLUSION: For small HTX initially observed, number of rib fractures and initial volume predicted delayed HTX-related intervention.
Assuntos
Hemotórax , Ferimentos não Penetrantes , Humanos , Estudos Retrospectivos , Masculino , Feminino , Adulto , Ferimentos não Penetrantes/terapia , Ferimentos não Penetrantes/diagnóstico por imagem , Pessoa de Meia-Idade , Hemotórax/etiologia , Hemotórax/terapia , Tomografia Computadorizada por Raios X , Traumatismos Torácicos/terapia , Traumatismos Torácicos/diagnóstico por imagem , Drenagem , Fatores de Risco , Fraturas das Costelas/terapia , Fraturas das Costelas/diagnóstico por imagemRESUMO
BACKGROUND: Oral anticoagulation is becoming more common with the aging population, which raises concern for the risk of invasive procedures that can cause bleeding, such as chest tube placement (thoracostomy). With the increase in CT imaging, more pneumothoraces and hemothoraces are being identified. The relative risk of thoracostomy in the presence of anticoagulation is not well-established. The objective of this study was to determine whether pre-injury anticoagulation affects the relative risk of tube thoracostomy following significant chest trauma. METHODS: This retrospective cohort study used data from the 2019 American College of Surgeons-Trauma Quality Program (ACS-TQP) database using R version 4.2.2. Data from the database was filtered based on inclusion and exclusion criteria. Outcomes were then assessed with the population of interest. Demographics, vitals, comorbidities, and injury parameters were also collected for each patient. This study included all adult patients (≥18 years) presenting with traumatic hemothorax, pneumothorax, or hemopneumothorax. Patients with missing data in demographics, vitals, comorbidities, injury parameters, or outcomes, as well as those with no signs of life upon arrival, were excluded from the study. Patients were stratified into groups based on whether they had pre-injury anticoagulation and whether they had a chest tube placed in the hospital. The primary outcome was mortality, and the secondary outcome was hospital length of stay (LOS). Logistic and standard regressions were used by a statistician to control for age, sex, and Injury Severity Score (ISS). RESULTS: Our study population included 72,385 patients (4250 with pre-injury anticoagulation and 68,135 without pre-injury anticoagulation). Pre-injury anticoagulation and thoracostomy were each independently associated with increased mortality and LOS. However, there was a non-significant interaction term between pre-injury anticoagulation and thoracostomy for both outcomes, indicating that their combined effects on mortality and LOS did not differ significantly from the sum of their individual effects. CONCLUSION: This study suggests that both pre-injury anticoagulation and thoracostomy are risk factors for mortality and increased LOS in adult patients presenting with hemothorax, pneumothorax, or hemopneumothorax, but they do not interact with each other. We recommend further study of this phenomenon to potentially improve clinical guidelines. LEVEL OF EVIDENCE: Therapeutic, Level III.
Assuntos
Anticoagulantes , Tubos Torácicos , Hemotórax , Pneumotórax , Traumatismos Torácicos , Toracostomia , Humanos , Estudos Retrospectivos , Masculino , Feminino , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Pessoa de Meia-Idade , Toracostomia/métodos , Traumatismos Torácicos/complicações , Adulto , Pneumotórax/etiologia , Hemotórax/etiologia , Idoso , Estados Unidos/epidemiologia , HemopneumotóraxRESUMO
INTRODUCTION: Screening for pneumothorax (PTX) is standard practice after thoracostomy tube removal, with postpull CXR being the gold standard. However, studies have shown that point-of-care thoracic ultrasound (POCTUS) is effective at detecting PTX and may represent a viable alternative. This study aims to evaluate the safety and efficacy of POCTUS for evaluation of clinically significant postpull PTX compared with chest x-ray (CXR). METHODS: We performed a prospective, cohort study at a Level 1 trauma center between April and December 2022 comparing the ability of POCTUS to detect clinically significant postpull PTX compared with CXR. Patients with thoracostomy tube placed for PTX, hemothorax, or hemopneumothorax were included. Clinically insignificant PTX was defined as a small residual or apical PTX without associated respiratory symptoms or need for thoracostomy tube replacement while clinically significant PTX were moderate to large or associated with physiologic change. RESULTS: We included 82 patients, the most common etiology was blunt trauma (n = 57), and the indications for thoracostomy tube placement were: PTX (n = 38), hemothorax (n = 15), and hemopneumothorax (n = 14). One patient required thoracostomy tube replacement for recurrent PTX identified by both ultrasound and X-ray. Thoracic ultrasound had a sensitivity of 100%, specificity of 95%, positive predictive value of 60%, and negative predictive value of 100% for the detection of clinically significant postpull PTX. CONCLUSIONS: The use of POCTUS for the detection of clinically significant PTX after thoracostomy tube removal is a safe and effective alternative to standard CXR. This echoes similar studies and emphasizes the need for further investigation in a multicenter study.
Assuntos
Tubos Torácicos , Remoção de Dispositivo , Pneumotórax , Toracostomia , Ultrassonografia , Humanos , Pneumotórax/etiologia , Pneumotórax/diagnóstico por imagem , Toracostomia/instrumentação , Toracostomia/efeitos adversos , Toracostomia/métodos , Masculino , Feminino , Estudos Prospectivos , Adulto , Pessoa de Meia-Idade , Tubos Torácicos/efeitos adversos , Radiografia Torácica , Adulto Jovem , Hemotórax/etiologia , Hemotórax/diagnóstico por imagem , Hemotórax/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico , Idoso , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico por imagemRESUMO
PURPOSE: The aim of this case report is to report that delayed hemothorax is possible after anterior vertebral body tethering (aVBT) and to illustrate the course of treatment. METHODS: We present a 15-year-old boy with adolescent idiopathic scoliosis who underwent an anterior thoracoscopic assisted vertebral body tethering who developed a massive right-sided hemothorax 12 days post-operatively. A chest tube was placed to drain the hemothorax and later required embolectomy with tissue plasminogen activator (TPA) to drain the retained hemothorax. RESULTS: At 1 month follow up post discharge the patient was asymptomatic, and radiograph did not demonstrate evidence of residual hemothorax and scoliosis. We have followed this patient for 5 years postoperative and he continues to do well clinically and radiographically. CONCLUSIONS: Pulmonary complications are a known drawback of anterior thoracoscopic spinal instrumentation. Delayed hemothorax is possible after aVBT. In the case of a retained hemothorax, chest tube treatment with TPA is a safe and effective method of embolectomy.
Assuntos
Hemotórax , Escoliose , Humanos , Escoliose/cirurgia , Masculino , Adolescente , Hemotórax/etiologia , Hemotórax/cirurgia , Hemotórax/diagnóstico por imagem , Corpo Vertebral/cirurgia , Corpo Vertebral/diagnóstico por imagem , Ativador de Plasminogênio Tecidual/uso terapêutico , Complicações Pós-Operatórias/etiologia , Fusão Vertebral/efeitos adversos , Resultado do Tratamento , Embolectomia/métodos , Toracoscopia/métodosRESUMO
BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is a practical resource in the management of traumatic hemothorax. However, it carries inherent risks and should be mobilized cost-effectively. In this study, we investigated the ideal VATS timing using cost analysis. METHODS: 617 cases of unilateral traumatic hemothorax from 2012 to 2022 were identified in our trauma database. We extracted encounter cost, length of stay (LOS), and operative cost information. Using Kruskal-Walli's test, we compared the cost and LOS for patients who underwent VATS or continued nonoperative management in the first 7 days of admission. Additionally, we computed the daily proportion of patients initially managed nonoperatively but ultimately underwent VATS. P-values <.05 were considered significant. RESULTS: The median encounter cost of cases managed operatively before hospital day 4 (HD4) was higher than those managed nonoperatively. This difference was $63k on HD2 (P-value .07) and was statistically significant for HD3 (difference of $65k, P-value .02). The median LOS with operational management on HD2 and 3 was 7 and 6 respectively vs median LOS of 2 and 3 with nonoperative management on those days (P-value <.001, .01 respectively). The proportion of patients who failed nonoperative management did not change from baseline until HD4 (23% (95% CI 19.7, 26.3) vs 33.9% (95% CI 28.3, 39.6), P-value <.001). DISCUSSION: Early mobilization of VATS before hospital day 4 increases the overall hospital cost without offering any length of stay benefit. Continuing nonoperative management longer than 4 days is associated with a high failure rate and a costlier operation.
Assuntos
Hemotórax , Tempo de Internação , Traumatismos Torácicos , Cirurgia Torácica Vídeoassistida , Humanos , Hemotórax/cirurgia , Hemotórax/etiologia , Hemotórax/terapia , Tempo de Internação/estatística & dados numéricos , Masculino , Feminino , Adulto , Traumatismos Torácicos/complicações , Traumatismos Torácicos/cirurgia , Estudos Retrospectivos , Pessoa de Meia-Idade , Tempo para o TratamentoRESUMO
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.
Assuntos
Tubos Torácicos , Hemotórax , Pneumotórax , Traumatismos Torácicos , Toracostomia , Humanos , Tubos Torácicos/efeitos adversos , Estudos Retrospectivos , Traumatismos Torácicos/terapia , Traumatismos Torácicos/complicações , Masculino , Feminino , Hemotórax/etiologia , Hemotórax/terapia , Adulto , Toracostomia/instrumentação , Pneumotórax/terapia , Pneumotórax/etiologia , Resultado do Tratamento , Pessoa de Meia-Idade , Hemopneumotórax/etiologia , Hemopneumotórax/terapia , Padrões de Prática Médica/estatística & dados numéricosAssuntos
Serviço Hospitalar de Emergência , Hemotórax , Fraturas das Costelas , Humanos , Hemotórax/etiologia , Hemotórax/diagnóstico por imagem , Fraturas das Costelas/complicações , Fatores de Risco , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Estudos Retrospectivos , Adulto , Fatores de TempoRESUMO
BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.