May the initial CT scan predict the occurrence of delayed hemothorax in blunt chest trauma patients?

Prediction Model of Delayed Hemothorax in Patients with Traumatic Occult Hemothorax Using a Novel Nomogram

Background

Delayed hemothorax (dHTX) can occur unexpectedly, even in patients who initially present without signs of hemothorax (HTX), potentially leading to death. We aimed to develop a predictive model for dHTX requiring intervention, specifically targeting those with no or occult HTX.

Methods

This retrospective study was conducted at a level 1 trauma center. The primary outcome was the occurrence of dHTX requiring intervention in patients who had no HTX or occult HTX and did not undergo closed thoracostomy post-injury. To minimize overfitting, we employed the least absolute shrinkage and selection operator (LASSO) logistic regression model for feature selection. Thereafter, we developed a multivariable logistic regression (MLR) model and a nomogram.

Results

In total, 688 patients were included in the study, with 64 cases of dHTX (9.3%). The LASSO and MLR analyses revealed that the depth of HTX (adjusted odds ratio [aOR], 3.79; 95% confidence interval [CI], 2.10-6.85; p<0.001) and the number of totally displaced rib fractures (RFX) (aOR, 1.90; 95% CI, 1.56-2.32; p<0.001) were significant predictors. Based on these parameters, we developed a nomogram to predict dHTX, with a sensitivity of 78.1%, a specificity of 76.0%, a positive predictive value of 25.0%, and a negative predictive value of 97.1% at the optimal cut-off value. The area under the receiver operating characteristic curve was 0.832.

Conclusion

The depth of HTX on initial chest computed tomography and the number of totally displaced RFX emerged as significant risk factors for dHTX. We propose a novel nomogram that is easily applicable in clinical settings.

Commentary: Prediction Model of Delayed Hemothorax in Patients with Traumatic Occult Hemothorax Using a Novel Nomogram

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Small Hemothoraces Not Drained on Admission: Initial Volume Predicts Need for Intervention

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.

Risk factors for delayed hemothorax in patients with rib fracture in the emergency department

OBJECTIVES

Although rib fractures are a risk factor, not all rib fracture patients will develop delayed hemothorax. This study aimed to evaluate risk factors which can identify rib fracture patients in the emergency department who may develop delayed hemothorax.

METHODS

Adult patients seen in the emergency room between January 2016 and February 2021 with rib fractures caused by blunt chest trauma were included in this retrospective observational study. Patients who underwent chest tube insertion within 2 days and those without follow-up chest radiographs within 2-30 days were excluded. We used a stepwise backward-elimination multivariable logistic regression model for analysis.

RESULTS

A total of 202 patients were included in this study. The number of total (P < 0.001), lateral (P = 0.019), and displaced (P < 0.001) rib fractures were significantly associated with delayed hemothorax. Lung contusions (P = 0.002), and initial minimal hemothorax (P < 0.001) and pneumothorax (P < 0.001) were more frequently associated with delayed hemothorax. Age (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.00-1.06, P = 0.022), mechanical ventilator use (aOR 9.67, 95% CI 1.01-92.75, P = 0.049), initial hemothorax (aOR 2.21, 95% CI 1.05-4.65, P = 0.037) and pneumothorax (aOR 2.99, 95% CI 1.36-6.54, P = 0.006), and displaced rib fractures (aOR 3.51, 95% CI 1.64-7.53, P = 0.001) were independently associated with delayed hemothorax.

CONCLUSIONS

Age, mechanical ventilation, initial hemo- or pneumothorax, and displaced rib fractures were risk factors for delayed hemothorax. Patients with these risk factors, and especially those with ≥2 displaced rib fractures, require close chest radiography follow-up of 2-30 days after the initial trauma.

Life-saving emergency surgery due to delayed massive hemothorax 7 days after fall injury: a case report

BACKGROUND

Delayed hemothorax after thoracic trauma complicates approximately 7.4-36% of blunt traumas. Cases of delayed hemothorax that suddenly increase and require surgery are rare. We report a case of delayed massive hemothorax that was not relieved by vascular embolization but was successfully treated with surgery.

CASE PRESENTATION

The patient was a 45-year-old man. He was rushed to the emergency room after falling from the 4th floor, and he underwent emergency surgery. The patient was weaned off the ventilator on postoperative day (POD) 3 but had bleeding of 500 ml/h from his left chest drain on POD 7. We initially performed intrathoracic angiography for the bleeding. Bleeding from the 9th and 10th intercostal arteries was confirmed. Although vascular embolization was performed, 6 h later, 500 ml/h of bleeding was observed again from the drain, and emergency surgery was performed. We performed ligation of the left 9th and 10th intercostal arteries and intrathoracic hematoma removal. The patient was weaned off the ventilator 14 days after the second surgery and was transferred for rehabilitation on day 50.

CONCLUSIONS

It is necessary to constantly monitor chest drainage and hemodynamics, especially within 7 days after injury, and to consider the possibility of emergency surgery.

[Intervention for Chest Trauma and Large Vessel Injury]

Trauma is an injury to the body that involves multiple anatomical and pathophysiological changes caused by forces acting from outside the body. The number of patients with trauma is increasing as our society becomes more sophisticated. The importance and demand of traumatology are growing due to the development and spread of treatment and diagnostic technologies. In particular, damage to the large blood vessels of the chest can be life-threatening, and the sequelae are often severe; therefore, diagnostic and therapeutic methods are becoming increasingly important. Trauma to non-aortic vessels of the thorax and aorta results in varying degrees of physical damage depending on the mechanism of the accident and anatomical damage involved. The main damage is hemorrhage from non-aortic vessels of the thorax and aorta, accompanied by hemodynamic instability and coagulation disorders, which can be life-threatening. Immediate diagnosis and rapid therapeutic access can often improve the prognosis. The treatment of trauma can be surgical or interventional, depending on the patient's condition. Among them, interventional procedures are increasingly gaining popularity owing to their convenience, rapidity, and high therapeutic effectiveness, with increasing use in more trauma centers worldwide. Typical interventional procedures for patients with thoracic trauma include embolization for non-aortic injuries and thoracic endovascular aortic repair for aortic injuries. These procedures have many advantages over surgical treatments, such as fewer internal or surgical side effects, and can be performed more quickly than surgical procedures, contributing to improved outcomes for patients with trauma.

Delayed Tension Hemothorax With Nondisplaced Rib Fractures After Blunt Thoracic Trauma

Blunt thoracic trauma often causes rib fractures, hemothorax, and pneumothorax. Although there is no established definition regarding the duration and management of delayed hemothorax, it commonly occurs in a few days and exhibits at least one displaced rib fracture. Moreover, delayed hemothorax rarely develops tension hemothorax. A 58-year-old male who had a motorcycle accident received conservative treatment from his orthopedic doctor. He felt a sudden severe chest pain 19 days after the accident. Contrast-enhanced computed tomography (CT) of the chest revealed multiple left-sided rib fractures without displacement, left pleural effusion, and extravasation near the intercostal space of the seventh rib fracture. After transfer to our hospital and a plain CT scan, which showed a more mediastinal shift toward the right, his condition deteriorated with cardiorespiratory embarrassment, such as restlessness, hypotension, and neck vein distention. We diagnosed him with obstructive shock due to tension hemothorax. Immediate chest drainage ameliorated restlessness and elevated blood pressure. Here, we report an extremely rare and atypical case of delayed tension hemothorax after blunt thoracic trauma without displaced rib fractures.

The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures

BACKGROUND

Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture.

METHODS

All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders.

RESULTS

96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome.

CONCLUSIONS

Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.

Imaging Manifestations of Chest Trauma

Trauma is the leading cause of death among individuals under 40 years of age, and pulmonary trauma is common in high-impact injuries. Unlike most other organs, the lung is elastic and distensible, with a physiologic capacity to withstand significant changes in contour and volume. The most common types of lung parenchymal injury are contusions, lacerations, and hematomas, each having characteristic imaging appearances. A less common type of lung injury is herniation. Chest radiography is often the first-line imaging modality performed in the assessment of the acutely injured patient, although there are inherent limitations in the use of this modality in trauma. CT images are more accurate for the assessment of the nature and extent of pulmonary injury than the single-view anteroposterior chest radiograph that is typically obtained in the trauma bay. However, the primary limitations of CT concern the need to transport the patient to the CT scanner and a longer processing time. The American Association for the Surgery of Trauma has established the most widely used grading scale to describe lung injury, which serves to communicate severity, guide management, and provide useful prognostic factors in a systematic fashion. The authors provide an in-depth exploration of the most common types of pulmonary parenchymal, pleural, and airway injuries. Injury grading, patient management, and potential complications of pulmonary injury are also discussed. ^©RSNA, 2021.

Delayed massive hemothorax due to diaphragm injury with rib fracture: A case report

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Diaphragmatic injury can cause delayed hemothorax.

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A thoracotomy should be considered in patients with delayed hemothorax and shock.

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Delayed hemothorax required surgery to control bleeding from diaphragmatic injury.

Introduction

Delayed massive hemothorax after blunt trauma is rare, although associated with significant morbidity and mortality. In most cases, the intercostal artery is the main bleeding source. We report a rare case of delayed massive hemothorax due to a diaphragm injury with a lower rib fractures.

Presentation of case

A 58-year-old man, transported to our hospital four hours after a 2-meter fall from a ladder, had left-sided fractures to ribs 11 and 12, thoracic and lumbar vertebral fractures, and traumatic subarachnoid hemorrhage. On admission, no left hemothorax was documented; however, 17 h post-injury he developed hypovolemic shock. Plain chest radiographs showed a massive left hemothorax with a mediastinal shift. Chest contrast-enhanced computed tomography revealed extravasation of the contrast agent in the chest cavity. No intercostal arterial bleeding was evident on emergency angiography. A left anterolateral thoracotomy through the 6th intercostal space revealed rib fractures and active bleeding from the dorsal side of the left hemidiaphragm. Suture hemostasis was performed for the diaphragm injury and the disrupted ribs were repaired.

Discussion

Embolization of diaphragm-feeding arteries is not a simple or fast procedure. Clinically, predicting delayed hemothorax is challenging, and careful observation of trauma patients with lower rib fractures is needed. Thoracotomy should be considered for immediate hemostasis in patients with sudden shock, with complete hematoma drainage and repair of the disrupted rib.

Conclusion

Diaphragmatic injury with lower rib fractures can result in delayed hemothorax, requiring thoracotomy.