40 y/asian/gentleman, NKMI presented to casualty department after had an MVA between a motorbike vs car. He is under the influence of alcohol. He was brought in by the passerby and no further history able to obtained at the point.
Upon arrival the patient is confused, the GCS was 14/15 - e4v4m6, patient was unable to recall any mechanism of injury. The primary survey conducted as below;
Trachea center, reduce air entry at the left side with dullness on percussion. Heart sound able to be heard well, s1s2 no murmur noted. No open wound at the chest noted, no paradoxical movement on the chest wall at any time. No congested neck veins.
The initial vital signs are as below
- BP - 70/50mmHg
- PR - 80bpm
- spo2 - 85% under RA, 100%under non-re-breathing mask @ 10L/min
- Resp.Rate - 24breath/min
- Glucose - 7.5mmol/L
- Rhythm strip shows sinus rhythm, with no ST changes
Secondary survey reveals patient had no allergic history, not on any medication and unable to recall last meal and the mechanism of injury.
Head to toe examinations reveal:-
- Laceration wound at the chin -4x2 cm with bone exposed
- Multiple avulsed tooth
- Left chest spring positive
- Abdomen soft non tender, not distended
- pelvic spring negative
- left shin deformed with a puncture wound - no active bleed noted, DPA/PTA are both felt well. Sensation intact
- Spinal examination reveal no abnormalities/tender , anal tone is intact.
- CBD - clear urine
Extended FAST done:-
- No FF noted in the abdomen (x3)
- Left pleural fluid collection, Sliding sign however still be able to be seen
- No pericardial effusion noted
Patient was resuscitated with 1.5L of Nsaline + 0.5L Gelafusin. BP was then pickup to 115/65, PR 80, spo2 100%
Chest tube was not inserted in the first place in view of patient have been stabilized and massive haemothorax is in doubt in view of tracheal still in center position.
Immediate CXR was performed and reveal complete ossification over the left side of the chest wall. Chest tube was inserted at the left side and anchored at 8cm.
Chest tube was inserted at the left side, the initial blood drained is 600ml of blood.
Chest tube was still fluctuant however minimal oozing of blood noted - over 2H the drain tube is around 1000cc of blood.
Patient was stable with blood transfusion in progress. Initial consultation to the Cardiothoracic team had been done but the diagnosis of massive haemothorax was then not established and observation is then was ordered and to reconsult back if:
- 200cc blood drain/ hour in the next 3 consequative hours
- 500-600cc of blood drain in the next hour
The blood results are as follows:-
- Hb - 11.0
- Wbc - 5.9
- Plt - 250
- pH - 7.21
- Hco3 - 17
- PaO2 - 180mmhg
- PaCO2 - 35mmhg
- BE - (-2)
- PT/APTT/INR - Normal
- Renal Profile - Normal
He was then on blood transfusion and 1 cycle of DIVC regime was given.
Patient was stable throughout the 2H of the initial presentation and was planned for admission.
Suddenly the chest tube Drain another 1800 cc of bright red blood in less then 5min. Patient collapse and went into cardiac arrest. He was pushed with blood and fluids, IV NaHCO3 50cc given, and went into Ventricular fibrillation. Defibrillation x 3 + IV amiodarone 300mg bolus given and CPR was commenced but patient succumbed.
Now lets talk, the pitfalls and how this things could be improved
1. Why is the chest tube was not inserted at the first place? Is all haemothorax equal to chest tube?
Answer: During the practice of medicine there is always people in doubt in making up diagnosis. In this case the diagnosis of haemothorax was done in the first place but the physician waited for the chest xray to confirm the diagnosis. It is however noted that the vital signs in this patient remain well after the initial resuscitation but what have gone wrong here????
We should go back to the class of hypovolemic shock. In this patient the blood loss is equal to the 3rd class of hypovolemic shock in which both of his SBP and DBP was then low. In class 3 shock the amount of blood that lost is around 1500 - 2000cc. Was that is not enough to make the diagnosis of this patient might have the massive haemothorax? Of course the patient had an open midshaft tibia (was not told then the xray shows midshaft tibia fracture) but at that moment there is no active bleed from there.
Is all haemothorax equal to chest tube? should we insert one if the diagnosis by clinically and supported by the BEDSIDE ultrasound was made in this case? why is there a hesitancy to insert the chest tube immediately?
If you read http://www.east.org/research/treatment-guidelines/hemothorax-and-occult-pneumothorax,-management-of you will find in the
Management of Hemothorax
- All hemothoraces, regardless of size, should be considered for drainage (Level 3).
- Attempt of initial drainage of hemothorax should be with a tube thoracostomy (Level 3)
and in http://www.madsci.com/manu/trau_che.htm recite this
Treatment: Remove the blood of a moderate-sized hemothorax by chest tube, even if the blood accumulation is not enough to interfere with respiration. As thrombolytic substances are released by the old blood, bleeding often continues. Placement of a chest tube also serves to tamponade bleeding by bringing the lung surface up against the chest wall. The tube must be large (36-40), and should be aimed posteriorly. Most cases of hemothorax do not require operation unless bleeding continues.
so what is the "moderate" size of hemothorax is?? what are mild-moderate-severe haemothorax classification are? i cant found one.
therefore i'll choose the east.org advise.
no more hesitancy should be in the initiation of chest tube drainage! :D
2. The use of extended FAST in haemothorax, how efficient and how good FAST can be in detecting pleural fluid collections?
The classical erect chest x-ray needed somewhere around 400-500ml of blood to obliterate the costophrenic angle of patient with haemothorax but using FAST you would be able to see haemothoraces at lesser amount of blood loss in the pleural fluid. However as all well known the ultrasound is user dependent and even with this case the first person who performed the initial extended FAST scan fail to pickup the pleural collections.
3. What are the indication of Cardiorespiratory Surgeon referral in this type of cases?.
In our practice, if the initial blood that come out from the chest tube insertion is equal or > 1500cc of blood or 200cc of blood/hour for 3 consequative hours the diagnosis of MASSIVE HAEMOTHORAX was made, and that is where the cardiothoracic surgeon will come in and accept the case.
Should this patient wait for the diagnosis or it should be accepted earlier?
i would say that this should be accepted earlier.. why?
if you read the above statement that at least 400-500mls of blood will be need to obstruct the costophrenic ange in ERECT position, in SUPINE position, one would miss a haemothorax even with 1000cc of blood had been lost.
In Tintinalli's Emergency Medicine 7th edition in page 1745 quote this:-
Each hemithorax can potentially hold approximately 40% of a patient's circulating blood volume. A massive haemothorax defined in the adult at least 1500ml, or approximately two thirds of the available space in the hemithorax.
and lower down you will see
Evacuation of >1500 ml of blood immediately after chest tube thoracostomy or 200ml of blood per hour for 4 hours are generally recognized definition of massive haemothorax and are indication for operative management. Even in patients not meeting this criteria, evidence of ongoing haemorrhage or rebleeding may warrant consideration of an operative intervention.
isnt that a bit mess out? if the chest radiograph as in this patient itself, could it not be a massive haemothorax? The draining of fluids through the chest tube insertion are depend on how the chest tube was inserted. We should however remember that the chest tube is inserted in the safety triangle which consist of :-
- Roof: lower edge of the pectoralis major
- Floor: imaginary line of the mid axillary line
- Wall : 3rd - 4th intercoastal space.
and how many intercoastal spaces that lung would cover? Each side of the lung field can hold up to 3000ml of fluids. Therefore if the patient came in with this kind of lung view from a chest x-ray would the consideration for early operative management be done? or should we stick with the diagnosis established through the definition of massive haemothorax?
Of course we should remember that not all hazziness are due to fluids in lungs, sometimes a very bad lung contusion may mimic as one.
I hope someone will make comments on this so that i can clear my mind up and for a better perspective especially in the cardiothoracic view of this type of cases. I am sure that there will be good explaination about this but till this case was written this is my view of this current problems, especially in where we have no access in Cardiothoracic team in the house~ we need to travel 100km for them :(
4. Whats make up the bright red blood in the chest tube that suddenly filled the 1800cc of chest drain in less then 5min. What would be the differential diagnosis in this case??
the bright red blood in the chest tube can is most probably an arterial in origin? Left sided haemothorax may also include the injury to the great vessels ie- the aorta or maybe iatrogenic injury to the heart itself during the insertion of the chest tube.
It is now advisable as a standard practice to do the open method of chest tube insertion rather that the old close method techniques. The open method will have a bigger incision but realtively more safe. The old method of chest tube insertion is doing the skin incision and to insert the chest tube using the trocha inside the tube.
In this kind of situation, if the injury lead to suspected arterial in origin especially the left side, a CT Thorax might be needed if patient stable to rule out these great vessels injury prior to the operative measurement.
*all images will be added later - 12/11/11
