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Case 309

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Male patient, 68yo, taken by SAMU to the Emergency Department, after being hit by a car. He was admitted with cervical collar, complaining of pain in the left hemithorax. There was no loss of consciousness or vomiting. At examination: patent airways, hemodynamic stability, without neurological changes. FAST (Focused Assessment with Sonography for Trauma) showed no evidence of viscera lesion and no free fluid in the abdominal cavity. Chest X-ray was requested and, later, computed tomography (CT) of the chest.

Based on clinical history and imaging tests, in addition to costal arch fractures, one can diagnose:

a) Pulmonary laceration

25%

b) Pneumomediastinum

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c) Subcutaneous emphysema

25%

d) Hemothorax

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Image Analysis

Image 1: Simple chest radiography, posteroanterior incidence, orthostatic position. Opacity at the base of the left hemithorax with the "meniscus signal", compatible with ipsilateral pleural fluid accumulation (blue arrow). Fractures in left costal arches (red arrows). Indication of presence of left pneumothorax (yellow arrow). Small nodules in the right hemithorax (green arrows). Presence of right-sided thoracic scoliosis.

 

 

Image 2: Chest CT, axial cut, supracarinal level, mediastinal window, without intravenous injection of iodinated contrast medium. Fluid accumulation in the left pleural space, compatible with hemothorax (red arrow), associated with adjacent subpleural consolidation, compatible with subssegmentar atelectasis by compression or pulmonary contusion.

 

 

Image 3: Chest CT, axial cut, infracarinal level, lung window, without intravenous injection of iodinated contrast medium. Fluid accumulation in the left pleural space, compatible with hemothorax (blue arrow) associated with adjacent subpleural consolidation (yellow arrow), compatible with subssegmentar atelectasis by compression or pulmonary contusion. Costal arch fracture in the left posterior border (red arrow). Small calcified nodule in the right lung, compatible with residual granuloma.

Highlights

- Hemothorax is a common complication of blunt or penetrating thoracic trauma;

- The classic presentation of a pleural effusion in chest radiography in orthostatism is an opacity in the form of meniscus, with veiling of the ipsilateral costophrenic sinus;

- Chest CT is indicated for patients who are hemodynamically stable;

- Hemothorax presents in CT as an accumulation of fluid in the pleural space, with spontaneously elevated attenuation coefficients, without air bronchograms and without pulmonary "ground glass" opacities;

- Treatment is based on replacement of specific type blood simultaneous to thoracostomy and drainage in water seal. Instable patients may require emergency thoracotomy.

References

- Mahoozi H, Volmerig J, Hecker E. Modern Management of Traumatic Hemothorax. Journal of Trauma & Treatment. 2016;5(3):326-30.

- Boersma W, Stigt J, Smit H. Treatment of haemothorax. Respiratory Medicine. 2010;104(11):1583-1587.

- Mattox K, Moore E, Feliciano D. Trauma. 7th ed. McGraw-Hill Education; 2012.

- Muller C, Muller N. Tórax – Série Colégio Brasileiro de Radiologia. 2nd ed. Elsevier; 2017.

Author

Thiago Ruiz Rodrigues Prestes, 5th year medical student at Universidade Federal de Minas Gerais

E-mail: ruiz.thiago[at]hotmail.com

Supervisor

José Nelson Mendes Vieira, Professor of the Department of Anatomy and Image of the Faculty of Medicine of Universidade Federal de Minas Gerais

E-mail: zenelson.vieira[at]gmail.com

Reviewers

Lucas Raso, Joice Carneiro, Laio Paiva, Ricardo Mazilão, Profa. Viviane Parisotto

Translated by

Juliana Albano de Guimarães, 6th year medical student at Universidade Federal de Minas Gerais

Test question

(UFF-2014) Regarding post-traumatic hemothorax, it is correct to state that:

a) 15 to 20% of the patients can be treated with only drainage in water seal.

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b) Persistence of bleeding, after drainage in water seal, at a rate of 50 ml/hour for three to four consecutive hours is a formal indication of thoracotomy.

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c) Most of bleeding in the thorax is a result of lesions in the low pressure pulmonary circulation.

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d) Massive hemothorax is, by definition, the one in which at least 500 ml of blood is drawn after thoracic drainage.

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e) At physical examination, the majority of the patients usually present a decrease of the vesicular murmur and hypertimpanism to percussion of the injured lobe.

25%
   

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