American Journal of Emergency Medicine 32 (2014) 818.e3-818.e4

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American Journal of Emergency Medicine

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Case Report

Delayed massive hemothorax complicating simple rib fracture associated with diaphragmatic injury

Abstract

Traumatic hemothorax is potentially life threatening. Rib fractures are the commonest injury after chest trauma, which accounts for 10% of patients after trauma. A delayed massive hemothorax after simple rib fracture is rare. The possibility of delayed sequelae after chest trauma should be considered, and patients should be informed of this possibility. We present a case of this uncommon situation with delayed massive hemothorax caused by simple fracture of the lower ribs. Admission should be considered for close observation when presenting with fracture of the lower ribs because of the possibility of diaphragmatic injury or intra-Abdominal injury, even if a simple rib fracture is found initially.

Chest traumas comprise 10% to 15% of all traumas and are the cause of death in 25% of cases [1]. blunt chest trauma accounts for 70% of all thoracic injuries and is a frequent reason for thoracic Surgical consultation at the emergency department [2,3]. A massive hemothorax can be caused by an acute chest injury such as blunt Thoracic trauma or penetrating thoracic injury and can involve tearing of the intercostal arteries, laceration of the lung, or rupture of great vessels of the mediastinum [4]. Delayed massive hemothorax after a chest trauma is rare [2]. A life-threatening delayed massive hemothorax after a simple fracture of the lower ribs is rarely reported. The bleeding sources were difficult to confirm and diagnose initially. A 60-year-old man had a blunt contusion on his right chest resulted from falling down 6 days before admission. He visited an emergency department of a local hospital where fractures of the right 10th and 11th ribs were diagnosed, and conservative treatment was prescribed initially. However, he suddenly developed dull right-sided chest pain, rapidly increasing dyspnea and orthopnea 6 hours before

being sent to our emergency department.

He was awake and alert, and his blood pressure was 116/56 mm Hg, pulse rate was 102 beats/min, and respiration rate was 32 breaths/ min. Severe tenderness on his right lower chest with diminishing breath sounds and dullness percussion was found. Chest x-ray showed a right massive hydrothorax with slight trachea deviation to the left side (Fig. 1). A kidney-ureter-bladder x-ray showed fracture of the right 10th and 11th ribs (Fig. 2). Subsequently, his blood pressure declined to 72/40 mm Hg, and his pulse rate increased to 121 beats/min. Resuscitation with fluid and Blood components was given. A tube thoracostomy was placed urgently, and about 1700 mL of fresh blood was evacuated initially. His hemoglobin level declined to

6.3 g/dL. We performed an emergent limited right thoracotomy through the ninth intercostal space because of unstable hemodynamic status and found massive hemothorax. We found fractures of the 10th and 11th ribs and a 1-cm laceration near the central tendon of the

right hemidiaphragm with ongoing bleeding (Fig. 3). We repaired the laceration of the diaphragm and the fractured ribs. The total blood loss was about 5500 mL. After operation, he recovered uneventfully and was discharged on hospital day 8.

Lu et al [5] reported that the major mechanisms of chest trauma are motor vehicle accident (70%) and falls (22%), and 32% sustained 1 rib fracture, 32% with 2 rib fractures, and 36% with 3 rib fractures. Right-sided injury occurred more than left-sided injury (56%/43%), and initial pulmonary complications occurred more than delayed situations [5]. Delayed hemothorax is a rare situation that comprises 7.4% [2]. The most common causes of delayed hemothorax are motor vehicle accident and pedestrian accidents (80.9%) [2]. In one study, 71% of cases of delayed hemothorax were caused by multiple displaced rib fractures [6]. Delayed hemothorax resulting from blunt thoracic trauma can develop within 3 to 6 hours but may be delayed

Fig. 1. Chest x-ray showed a right massive hemothorax.

0735-6757/(C) 2014

818.e4 C.-L. Chen, Y.-L. Cheng / American Journal of Emergency Medicine 32 (2014) 818.e3-818.e4

Fig. 3. Under thoracoscopy, a 1-cm laceration of the right hemidiaphragm was found.

Fig. 2. A kidney-ureter-bladder x-ray showed fracture of the right 10th and 11th ribs (arrows).

for up to 30 days, although most patients (86%) are diagnosed within

4 days [6]. To our knowledge, this is a rare documented case of delayed massive hemothorax resulted from a simple fracture of the lower ribs without obvious displacement.

Fracture of the lower ribs as a result of blunt trauma can cause a laceration to the diaphragm. The clinical prodrome of a delayed massive hemothorax is the development of chest pain or worsening of preexisting chest discomfort accompanied by chest dyspnea [7]. In the emergency department, focused assessment with sonography for trauma is widely acceptable because of its high sensitivity and specificity for fluid accumulation in internal cavities [8]. However, it has diagnostic limitation in diaphragmatic injuries. Multislice com- puted tomography has higher specificity in solid Organ injuries [9]. However, it is not used routinely in the emergency department and is not readily available in all institutions. In addition, it is contra- indicated in patients with unstable hemodynamics.

The most important aspects of the management of delayed hemothorax are controlling bleeding and evacuating nonclotted blood from the Pleural cavity immediately [10]. A tube thoracostomy can provide adequate drainage of a hemothorax and can provide an index of persistent intrathoracic bleeding [7]. Thoracoscopy can provide a minimally invasive intervention for patients with stable hemodynamic status, but a thoracotomy should be considered for patients with an unstable hemodynamic condition. We performed an emergency thoracotomy in our patient because of his unstable hemodynamic status and the initial removal of 1700 mL of nonclotted blood through the chest tube.

In conclusion, a fracture of a lower rib or ribs might be accompanied by a delayed massive hemothorax, although it is rarely occurred. The possibility of delayed sequelae should be considered, and patients should be informed of this possibility. Further admission for observation should be considered, even if a simple rib fracture is found initially.

Chin-Li Chen, MD Yeung-Leung Cheng, MD

Division of Thoracic Surgery, Department of Surgery Tri-Service General Hospital, National Defense Medical Center

Taipei 114, Taiwan, ROC E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.12.060

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