Hemothorax

Delayed hemothorax after blunt trauma is a rare, significantly morbid entity described in the current literature associated with displaced rib fractures. This report describes a case of delayed hemothorax after blunt trauma without rib fracture. The patient presented to a routine clinic appointment 72 hours after injuring himself while snowboarding. Chest radiographs at initial visit were negative for significant pathology. Eight hours later, the patient presented again with worsening chest pain and dyspnea. Repeat radiographs revealed a large right-sided hemothorax. The patient was treated with tube thoracostomy and remained an inpatient for 6 days. This case is unique because, unlike previously reported delayed hemothorax after blunt trauma, this patient had no evidence of rib fractures.

Introduction

An infrequent phenomenon, delayed hemothorax after blunt trauma (DHBT) was first described as a clinical entity in 1998.1 This was described as a documented chest film or computed tomography (CT) without infiltrates after blunt chest trauma and the subsequent development of hemothorax 18 hours to 6 days later (mean, 3.1 days). The authors state that it is a "unique clinical entity that occurs almost exclusively in patients with multiple or displaced rib fractures." We present a case of DHBT in an adult without discernable rib fractures.

Case Report

A 28-year-old male army sergeant presented for a routine 9:00 a.m. appointment to the health clinic 72 hours after a 3-meter fall onto his right side while snowboarding. He had not previously sought medical attention before presentation. He complained of a pleuritic, right-sided chest pain without dyspnea as well as pain at the site of impact.

Physical findings were negative except for a 10-cm diameter patchy ecchymosis of the right flank located in a fat pad superolaterally to the right anterior superior iliac spine and tenderness to palpation in the same area.

Posterior-anterior (PA) and lateral ambulatory chest radiographs were benign, revealing no signs of rib fracture or infiltrates (Fig. 1). The patient was diagnosed with post-traumatic musculoskeletal complaints and discharged to home with 800-mg tablets of ibuprofen.

At 4:45 p.m. the patient again presented to the clinic with the complaint of precipitously worsening right-sided, lateral chest pain and the onset of dyspnea at rest. He appeared in mild distress and was clutching his right side. He had decreased breath sounds in the right base. PA and lateral ambulatory chest radiographs were repeated (Fig. 2), this time revealing a massive pulmonary infiltrate obscuring one-half of the right lung field.

After hospital admission, thoracostomy drained approximately 1,000 ml of bloody fluid and coagulated blood. Further attempts were made to remove pockets of fluid with pleural taps, which were mostly unsuccessful due to hemagglutination. The patient remained stable on room air, saturating 94% to 99%. The patient's symptoms improved modestly during the ensuing several days as further testing was performed. History confirmed that he had not consumed aspirin or any other antiplatelet drugs before or after the accident. He did take one 800-mg tablet of ibuprofen 24 hours after the accident and one 800-mg tablet after his 9:00 a.m. appointment. Coagulation studies were normal as was hemoglobin electrophoresis. Hemoglobin ranged from 13.0 on admission to a low of 8.3 on hospital day 3. An initial CT scan showed a large hemothorax with collapse of the right inferior lobe as well as partial collapse of the right middle lobe. There was no fracture seen. A second CT prior to discharge revealed the collapsed right inferior lobe with reinflation of the right middle lobe. Again, no fractures were seen. Having remained stable with diminishing pain but persistent pulmonary infiltrates on chest X-ray, the patient was discharged to home on hospital day 6.

Discussion

Delayed DHBT is an entity worthy of clinical note in the follow-up of patients treated and released after blunt trauma due to its significant morbidity.2 Simon and Quyen1 further elucidate that, "the prodrome of new-onset pleuritic chest pain or change in the nature of pre-existing chest discomfort associated with dyspnea is a constant theme" associated with DHBT. They also conclude that DHBT occurs almost exclusively in patients with multiple or displaced rib fractures.

The most common source of bleeding postulated for DHBT is an intercostal artery tear. Other documented causes include aortic penetration by migrating displaced rib fracture, diaphragmatic rupture, and bronchial and pulmonary arterial rupture.2-4 It has been associated with bouts of coughing and maximal respiratory effort,2 although our patient could not associate the onset of symptoms with either.

In the Simon and Quyen study,1 there were 12 documented cases of DHBT in a University Hospital over a 3-year period, all of which were associated with rib fractures. Also, Ross and Cordoba2 describe two cases of DHBT in association with rib fractures. Our patient underwent two CT scans, nine chest radiographs, and one examination under fluoroscopy without evidence of rib fracture. This case is unique because it documents DHBT in an adult in the absence of rib fractures.

References

1. Simon B, Quyen C: Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity. J Trauma 1998; 45: 673-6.

2. Ross R, Cordoba A: Delayed life-threatening hemothorax associated with rib fractures. J Trauma 1986; 26: 576-8.

3. Tsai FC: Blunt trauma with flail chest and penetrating aortic injury. Eur J Cardiothorac Surg 1999; 16: 374-7.

4. Ritter D, Chang F: Delayed hemothorax resulting from stab wounds to the internal mammary artery. J Trauma 1995; 39: 586-9.

Guarantor: CPT David W. Bundy, MC USA

Contributors: CPT David W. Bundy, MC USA; CPT Douglas M. Tilton, MC USA

Copyright Association of Military Surgeons of the United States Jun 2003
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