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Two cases of accidental entrance of the thorax with a vascular tunneler are reported. Passage of this instrument when performing axillofemoral bypass is probably safer when done in a cephalad-to-caudad direction. A counterincision at the costal margin may be helpful in avoiding the complication, especially when the tunneler is passed from the groin.

A spontaneous pneumothorax complicated by severe bleeding presents a potentially grave emergency. If bleeding continues, thoracotomy becomes necessary to control the hemorrhage, to evacuate residual blood and clots, and to repair the break in the continuity of the lung.

A case is reported of a patient who suffered a rupture of one lung as result of thoracic trauma. This gave rise to respiratory distress with massive haemoptysis which was initially treated with a double-lumen endotracheal tube, with separate lung ventilation, a chest drain and massive transfusion. A haemostatic pneumonectomy had to be performed because of the persisting and profuse bleeding.

Pneumothorax is a common clinical problem encountered by both surgical and medical physicians. Air leaks into the pleural space occur either spontaneously or as a result of traumatic tears in the pleura following chest injury or surgical procedures. Therapy is directed at removing air from the pleural space, re-expanding the underlying lung, and preventing recurrences.

Neither hemothorax nor pneumothorax are well recognized manifestations of systemic lupus erythematosus (SLE). Two patients with SLE who developed hemopneumothorax during the course of their illness are described. The clinical, laboratory, roentgenographic, and pathological findings are presented. Both patients were treated with chest tube suction, but 1 required surgical decortication of fibrinous pleural adhesions.

A prospective randomized study of 85 patients who had sustained trauma to the chest requiring closed tube thoracostomy is reported. They were segregated into two groups, one of which did not receive prophylactic cephapirin sodium. Although the series is somewhat abbreviated, it would appear that the use of prophylactic antibiotics merely for the presence of a chest tube is an unsettled issue and of no definitely proved benefit.

In a current review of the literature regarding the management of patients with suspected penetrating cardiac injuries there appears to be no place for conservative management. Nine patients with penetrating cardiac injuries were successfully treated conservatively and are reported. This series aims to emphasize the point that there is a place for conservative management of selected cases.

We have led over a four year period, from 1981 to 1985, a prospective study on all cases of penetrating chest wounds (77 cases) in the intensive Care unit and the Department of Thoracic Surgery at the Avicenne Hospital. These wounds, involving young males, are fortunately mostly benign. Their seriousness is based on the abdominal or mediastinal hemorrhage as well as lesions to the vital organs which need an emergency intervention. The latter, nevertheless, with the help of the mobile reanimation service for transfering the patient, has diminished the mortality rate to 2.6 per cent. Following their experiment and after a review of the literature, the authors expose their method of management of the penetrating chest wounds.

Our experience indicates a continued rising incidence of gunshot wounds of the chest in the United States. During the past 4 1/2 years, 250 consecutive cases were treated at the King-Drew Medical Center in Los Angeles. Ninety per cent presented with a haemothorax or haemopneumothorax. Pneumothorax alone was present in only 3 per cent of cases. Twenty per cent had associated intra-abdominal injuries, involving mostly the diaphragm, liver, spleen and the gastrointestinal tract. Eighty per cent were treated with tube thoracostomy and among these there were 2 deaths, neither being related to the chest injury. About 16 per cent underwent thoracotomy with a mortality of 12.8 per cent, all the deaths being caused by severe cardiac wounds. The overall mortality was 2.8 per cent. The complication rate was 5.3 per cent, most complications occurring in patients with associated intra-abdominal and spinal cord injuries. The average period of hospitalization was 6.5 days. The management plan and the indications for the two courses of therapy are discussed.

This discussion of pulmonary lesions caused by blunt chest injury points out the importance of chest X-rays, particularly in the case of costal fractures, contusion of the lungs, and respiratory distress syndrome.

1. The article introduces a patient with left-side haemangioma capillare of the pleura parietalis with haemopneumothorax and ipsilateral cystic changes of the left upper lobe of the l,ng. 2. The aetiopathogenesis of the disease is discussed as an abortive type of Rendu-Osler-Weber disease (hereditary haemorrhagic telangiectasia), the diagnosis being based exclusively on histological findings as the only possibility of diagnosis. 3. The therapeutic approach is discussed.

The incidence of penetrating wounds of the chest is rising rapidly. Opinions continue to differ on their management. Our experience with 200 consecutive cases of stab wounds of the chest between 1972 and 1975 were reviewed. There were 176 males and 24 females. The average age was 31 years; about two-thirds of the patients were under 30. About 74% presented with hemothorax or hemopneumothorax; 21 presented with pneumothorax. Eleven per cent had associated intra-abdominal injuries. Seventy-nine per cent were successfully treated with tube thoracostomy. About 15% underwent thoracotomy, with three deaths (mortality, 10%); the mortality for cardiac wounds was 16%; overall mortality was 1.5%. The overall complication rate was 5.5%, most occurring in patients with cardiac wounds and associated intra-abdominal injuries. The average period of hospitalization was 6.5 days. Treatment was individualized. Indications for each course of therapy are discussed.

In a prospective study, 85 patients underwent simple observation for minor injuries of the pleural cavity as a result of penetrating injury of the chest. Seven patients (8 per cent) required delayed drainage, because of an increase in the size of the pneumothorax and/or haemothorax, but in all cases drainage was instituted within 24 hours. Haemopneumothorax is the most likely underlying disorder to require delayed drainage. Subcutaneous emphysema is of no value for identifying those cases likely to need delayed drainage. Twenty-four hours is adequate for the observation of patients with slight effects of penetrating wounds of the chest.

A case of interlobar air-fluid collections following nonpenetrating chest trauma is presented. Radiographic features which suggest the diagnosis of traumatic fissural hemopneumothorax are discussed.

Haemothorax, haemopneumothorax, and pneumothorax were the most common complications in 85 patients with penetrating stab injuries of the chest. These complications were amenable to conservative treatment by aspiration or drainage of the pleural space. Immediate operation was indicated in 30 cases. Indications for surgery were haemorrhage from a major systemic or pulmonary vessel or the heart, cardiac tamponade, diaphragmatic penetration, oesophageal and bronchial tears, and sucking chest wounds. The need for immediate operation was clinically obvious at presentation in most cases. It should have been suspected from the situation of the entry wound, the nature of the weapon used, the size of the haemothorax, and the clinical findings in the others. All 11 deaths occurred in that group in which early operation was indicated, and some could have been averted had the need for operation been suspected early. Seven patients developed an empyema; five were in the group that required immediate surgery and in the other two infection occurred in a clotted haemothorax. Early repair of the associated visceral injuries and complete evacuation of a haemothorax, either fluid or clotted, could reduce the incidence of empyema.

Malignant hemangioendothelioma is a rare vascular tumor. The disease frequently recurs and eventually metastasizes to the lung in most cases. Hemopneumothorax developing soon after metastasis to the lung indicates on unfavorable prognosis. We had an opportunity to examine a patient who had malignant hemangioendothelioma in the occipital scalp and developed hemopneumothorax following metastasis to the lung. We report the computed tomographic (CT) and pathological finding in the patient, and review the literature on hemopneumothorax.