A Case Report of Delayed Hemothorax Complicated by Fibrothorax

Delayed hemothorax is a potentially life-threatening complication of thoracic trauma that should be carefully considered in all patients presenting with thoracic injury. We report a case of delayed hemothorax in a 77-year-old male presenting eleven days’ status post multiple right mid- to high-rib fractures. His case was complicated by retained hemothorax after CT-guided chest-tube with subsequent video-assisted tube thoracostomy (VATS) revealing fibrothorax necessitating conversion to open thoracotomy. Known risk factors for development of delayed hemothorax include older patient age, three or more rib fractures, and presence of mid- to high-rib fractures, and should be used in risk stratification of thoracic trauma. Tube thoracostomy is often sufficient in management of delayed hemothorax. In rare cases, hemothoraces can be complicated by retained hemothorax or fibrothorax, which require more invasive therapy and carry greater morbidity and mortality.

Optimal Initial Positioning of Chest Tubes to Prevent Retained Hemothorax Using a Novel Steerable Chest Tube With Extendable Infusion Cannula

ABSTRACT Introduction With blunt and penetrating trauma to the chest, warfighters and civilians frequently suffer from punctured lung (pneumothorax) and/or bleeding into the pleural space (hemothorax). Optimal management of this condition requires the rapid placement of a chest tube to evacuate as much of the blood and air as possible. Incomplete drainage of blood leading to retained hemothorax may be the result of the final tube tip position not being in contact with the blood collections. To address this problem, we sought to develop a “steerable” chest tube that could be accurately placed or repositioned into a specific desired position in the pleural space to assure optimal drainage. An integrated infusion cannula was added for the instillation of anticoagulants to maintain tube patency, thrombolytics for clot lysis, and analgesics for pain control if required. Materials and Methods A triple-lumen tube was designed to provide a channel for a pull-wire which was wound around an axle integrated into a small proximal handle and controlled by a ratcheted thumbwheel. Tension on the wire creates an arc on the tube that allows for positioning. In vitro testing focused on the relationship between the tension on the pull-wire and the resultant arc. Two adult cadavers and two anesthetized pigs were used to study the feasibility of accurate tube placement. After a brief training session, providers were asked to place tubes inferiorly along the diaphragm where blood was anticipated to accumulate or at the apex of the lung for pneumothorax. Success was determined with fluoroscopic images and was judged as a tube tip lying in the targeted position. Results The design was prototyped with an extruded polyvinyl chloride multilumen tube and a 3D printed tensioning handle. In vitro studies showed that one turn of the thumbwheel created 70° to 90° of arc of the tube. Cadaver and animal studies showed consistent success in the desired placement of the tube at or near the lateral diaphragm or in the apex. Attempts were also successful by surgical residents with minimal training. Conclusions Initial preliminary studies on a novel steerable chest tube have demonstrated the ability to appropriately position the tube in a desired location. The addition of an extendable cannula will allow for safe clot lysis or maintained tube patency. Additional studies are planned to confirm the benefit of this device in preventing retained hemothorax.

Agitation Techniques to Enhance Drainage of Retained Hemothorax

Background. Retained hemothorax (RH) is a common problem in cardiothoracic and trauma surgery. We aimed to determine the optimum agitation technique to enhance thrombus dissolution and drainage and to apply the technique to a porcine-retained hemothorax. Methods. Three agitation techniques were tested: flush irrigation, ultrasound, and vibration. We used the techniques in a benchtop model with tissue plasminogen activator (tPA) and pig hemothorax with tPA. We used the most promising technique vibration in a pig hemothorax without tPA. Statistics. We used 2-sample t tests for each comparison and Cohen d tests to calculate effect size (ES). Results. In the benchtop model, mean drainages in the agitation group and control group and the ES were flush irrigation, 42%, 28%, and 2.91 ( P = .10); ultrasound, 35%, 27%, and .76 ( P = .30); and vibration, 28%, 19%, and 1.14 ( P = .04). In the pig hemothorax with tPA, mean drainages and the ES of each agitation technique compared with control (58%) were flush irrigation, 80% and 1.14 ( P = .37); ultrasound, 80% and 2.11 ( P = .17); and vibration, 95% and 3.98 ( P = .06). In the pig hemothorax model without tPA, mean drainages of the vibration technique and control group were 50% and 43% (ES = .29; P = .65). Discussion. In vitro studies suggested flush irrigation had the greatest effect, whereas only vibration was significantly different vs the respective controls. In vivo with tPA, vibration showed promising but not statistically significant results. Results of in vivo experiments without tPA were negative. Conclusion. Agitation techniques, in combination with tPA, may enhance drainage of hemothorax.

Traumatic retained hemothorax: is it time for video assisted thoracoscopic surgery

Thoracic trauma is a significant cause of morbidity and mortality, if not treated promptly. 80% to 85% of chest injuries can be treated with chest tube insertion alone. However, in about four to 20% of population, there is incomplete clearance of hemothorax following tube insertion and can lead to a condition called retained hemothorax. The purpose of this review is to establish the role and effectiveness of Video assisted thoracoscopic surgery (VATS) in successful evacuation of retained hemothorax following blunt thoracic trauma. Relevant articles from databases like Pubmed, Google scholar, Medline and Cochrane library were included. A retained hemothorax is defined as the persistence of residual clots in the pleural cavity, which is radiologically evident, 72 hours following initial tube thoracostomy. The various options to manage this condition include observation, insertion of second thoracostomy tube, intrapleural fibrinolytic, VATS or thoracotomy. Based on review of existing studies, VATS evacuation was found to have shorter hospital stay, lesser costs and shorter duration of tube drainage. There was also lesser rate of conversion to thoracotomy as compared to other methods and fewer complications like fibrothorax and empyema. In hemodynamically unstable patients, which is a contraindication to VATS, use of intrapleural fibrinolytics like streptokinase may be considered as an alternative option to provide clearance of the retained hemothorax. Retained hemothorax, when encountered following thoracic trauma, can be effectively managed by VATS. The decision to use VATS for hemothorax evacuation should be made promptly for maximum results, especially within three to seven days following trauma.

Role of streptokinase in management of retained hemothorax: a multicentric study

Background: Enzymatic debridement of the pleural cavity for retained haemothorax is a frequently overlooked option.Methods: A retrospective, multicentre study was carried out using intrapleural streptokinase was carried out in 15 patients with retained or clotted haemothorax.Results: Thirteen of fifteen patients (86%) with retained pleural collections underwent successful enzymatic debridement and tube drainage with streptokinase injections in our study. The average increase in chest tube output following streptokinase injections was 160%. No significant adverse reactions occurred. Two patients required thoracotomy when streptokinase therapy failed. No deaths were reported in the study.Conclusions: Intrapleural streptokinase is a safe, effective means of removing retained proteinaceous collections in the pleural space. It is a useful adjunct to chest tube drainage and may obviate the need for more invasive procedures.