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Background: Spontaneous hemopneumothorax is a rare condition that can be life-threatening if not promptly diagnosed and treated. We report a case of early treatment with transcatheter arterial embolization and video-assisted thoracoscopic surgery., Case Presentation: A 19-year-old Japanese male was diagnosed with left pneumothorax and underwent chest tube drainage. A total of 10 hours after admission, the patient developed dyspnea, chest pain, and sudden massive bloody effusion. Contrast-enhanced computed tomography revealed contrast extravasation near the left lung apex, and spontaneous hemopneumothorax was diagnosed. Angiography revealed bleeding from a branch of the subscapular artery and transcatheter arterial embolization was performed. The patient underwent video-assisted thoracoscopic surgery and recovered uneventfully., Conclusions: Anesthesiologists involved in urgent surgeries must be aware that a patient with spontaneous pneumothorax can develop a hemopneumothorax, even when full lung expansion has been obtained following chest tube drainage, owing to latent aberrant artery disruption. Interprofessional team engagement is essential for spontaneous hemopneumothorax management., (© 2024. The Author(s).)

Background: The standard for managing traumatic pneumothorax (PTX), hemothorax (HTX), and hemopneumothorax (HPTX) has historically been large-bore (LB) chest tubes (>20-Fr). Previous studies have shown equal efficacy of small-bore (SB) chest tubes (≤19-Fr) in draining PTX and HTX/HPTX. This study aimed to evaluate provider practice patterns, treatment efficacy, and complications related to the selection of chest tube sizes for patients with thoracic trauma., Methods: A retrospective chart review was performed on adult patients who underwent tube thoracostomy for traumatic PTX, HTX, or HPTX at a Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between SB and LB thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern. Secondary outcomes included retained hemothorax, insertion-related complications, and duration of chest tube placement. Univariate and multivariate analyses were performed., Results: Three hundred and forty-one patients were included and 297 (87.1%) received LB tubes. No significant differences were found between the groups concerning tube failure and insertion-related complications. LB tubes were more frequently placed in patients with penetrating MOI, higher average ISS, and higher average thoracic AIS. Patients who received LB chest tubes experienced a higher incidence of retained HTX., Discussion: In patients with thoracic trauma, both SB and LB chest tubes may be used for treatment. SB tubes are typically placed in nonemergent situations, and there is apparent provider bias for LB tubes. A future randomized clinical trial is needed to provide additional data on the usage of SB tubes in emergent situations., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The Japan Society for Pneumothorax and Cystic Lung Disease conducted a nationwide retrospective survey to identify correlations between the timing of surgical intervention and the incidence of transfusion, and to examine the factors contributing to the need for transfusion among clinical features in surgically treated spontaneous hemopneumothorax (SHP) patients., Methods: We analyzed the characteristics and perioperative results of patients with SHP who underwent thoracoscopy or thoracotomy between April 2009 and March 2019., Results: From 17 institutions, 171 cases were enrolled in this study. Receiver-operating characteristic curve analyses for the incidence of transfusion and waiting time before the operation revealed an area under the curve of 0.54 (95% confidence interval [CI] 0.44-0.64). Therefore, we did not compare the clinical features using a cutoff value of waiting time before the operation. More than 80% of the patients underwent surgical treatment within 24 h from admission. Multivariate analysis revealed that the total volume of hemorrhage was the only significant factor contributing to the incidence of transfusion (p = 0.00011, odds ratio: 0.03, 95% CI 0.0051-0.18). Moreover, multivariate analyses revealed that the waiting time before the operation was a contributing factor for prolonged total hospitalization (p < 0.0001, estimated regression coefficient: 0.036, 95% CI 0.027-0.045)., Conclusion: In SHP patients, a reduction in the waiting time before the operation significantly contributed to not the avoidance of transfusion but a reduction in total hospitalization time. In addition, transfusion was performed depending on the volume of blood loss., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Ruptured intercostal aneurysm is a rare cause of spontaneous hemopneumothorax (SHP). A 29-year-old woman presented to our hospital with left neck pain and, in the emergency room, suddenly lost consciousness. Chest radiography showed massive pleural effusion and the moderate collapse of the left lung. A chest drain was placed and 800 mL of bloody pleural effusion was collected. Contrast-enhanced computed tomography showed a ruptured aneurysm near the left pulmonary apex. Emergency angiography further revealed the ruptured aneurysm in the second intercostal artery. Transcatheter angiographic embolization (TAE) was performed, which resulted in hemostasis. On hospitalization day 2, the hematoma was removed via video-assisted thoracic surgery. A bulla was also identified in the lower lobe and removed. She was discharged from the hospital on a postoperative day 6 without complications. Thus, TAE might be effective to control bleeding during the initial treatment of SHP due to a ruptured aneurysm.

Introduction: There are several complications associated with automated mechanical CPR (AM-CPR), including tension pneumothoraces. The incidence of these complications and the risk factors for their development remain poorly characterized. Tension hemopneumothorax is a previously unreported complication of AM-CPR. The authors present a case of a suspected tension hemopneumothorax that developed during the use of an automated mechanical CPR device. Case Description: A 67 year-old woman with a history of COPD and CABG was observed by an off-duty firefighter to be slumped behind the wheel of an ice cream truck that drifted off the road at a low rate of speed and was stopped by a wooden fence, resulting in only minor paint scratches. The patient was found to be in cardiac arrest with a shockable rhythm. No signs of trauma were noted, and equal bilateral breath sounds were present with BVM ventilation. After 13 minutes of manual CPR, fire department personnel applied their Defibtech LifeLine ARM mechanical CPR device to the patient. During resuscitation, the device had to be repositioned twice due to rightward piston migration off of the sternum. Seven minutes after AM-CPR application, the patient had absent right-sided breath sounds and ventilations were more difficult. Needle decompression was performed with an audible release of air. A chest tube was placed by an EMS physician and roughly 400 mL of blood were immediately returned. At the next 2-minute pulse check, ROSC was noted, and the patient was transported to the hospital. She had an ischemic EKG and elevated troponin. Chest CT showed emphysematous lungs, bilateral rib fractures, and a small right-sided pneumothorax. Despite aggressive measures, the patient's condition gradually worsened, and she died 48 hours after presentation. Discussion/Conclusion: Migration of AM-CPR device pistons may contribute to the development of iatrogenic injuries such as hemopneumothoraces. Patients with underlying lung disease may be at a higher risk of developing pneumothoraces or hemopneumothoraces during the course of AM-CPR. Awareness of these potential complications may aid first responders by improving vigilance of piston location and by providing quicker recognition of iatrogenic injuries that need immediate attention to improve the opportunity for ROSC.

Introduction: Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32-40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX., Methods: Prospective RCT comparing 14Fr PCs to 28-32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1-5 (1 = tolerable experience, 5 = worst experience). Unpaired Student's t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P < 0.05., Results: Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375-1087; for PCs vs. 400 ml; IR, 240-700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, "I can tolerate it"; IR, 1-2) than CT patients (median, 3, "It was a bad experience"; IR, 3-4, P = 0.001)., Conclusion: In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28-32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience. www.ClinicalTrials.gov Registration ID: NCT02553434.

Coronavirus disease 2019 (COVID-19) is primarily a febrile respiratory illness that was first documented in China in December 2019 and shortly after declared a pandemic on March 11, 2020. The pathophysiology of the virus is still not completely understood and remains under investigation. Consequently, new symptomatic manifestations and complications of the disease continue to be discovered. Here we present the case of a spontaneous hemopneumothorax resulting in hemorrhagic shock in an adult male with PCR confirmed COVID-19., (Published by Elsevier Inc.)

A 17-year-old man came to the hospital complaining of right back pain. He had a history of an emergency operation for a left idiopathic hemopneumothorax. A chest X-ray revealed right lung collapse and suggested pleural adhesion at the apex of the right lung. He was diagnosed with right spontaneous pneumothorax and the surgical treatment was performed, because pleural adhesion may cause the hemothorax. During surgery, several pleural adhesion bands were found in the thoracic cavity between the right lung apex and chest wall. Spontaneous pneumothorax with a pleural adhesion at the apex is considered to be the indication for surgery because of the risk of hemothorax.

Background: Spontaneous hemopneumothorax (SHP) is defined as the accumulation of >400 mL of blood in the pleural cavity in association with spontaneous pneumothorax. This rare clinical disorder may be life-threatening., Case Presentation: A 71-year-old woman presented with a 1-month history of recurrent bloody stool, and electronic colonoscopy suggested a rectal mass. Laparoscopic radical resection of rectal cancer was performed. Two days later, she developed chest tightness, shortness of breath, and slight pain in the left chest. Emergency chest radiography revealed mild left pneumothorax and pleural effusion. SHP was suspected and a thoracic drain was inserted. However, the patient developed hemorrhagic shock 3 hours after drainage. She underwent emergency video-assisted thoracic surgery (VATS), which revealed left lung tip rupture with bleeding and adhesive band fracture at the top of the left thoracic cavity. The ruptured lung tissue was removed and electrocoagulation at the adhesion band was performed for hemostasis. The patient was discharged on postoperative day 11. At the time of this writing, she had developed no SHP recurrence or any other complications., Conclusions: This case shows that conservative treatment may have serious consequences in patients with SHP. Thus, chest X-ray examination and VATS should be performed in patients with SHP.

Background : Angiosarcoma is a rare and aggressive tumor of vascular endothelial origin. Pulmonary metastasis can lead to potential life-threatening complications, such as bleeding and pneumothorax. Methods : We report on a 82-year-old male with major hemoptysis, recurrent hemopneumothorax and cystic lung lesions. Results : Although initial diagnostic findings were misleading, thoracoscopic exploration revealed pulmonary and pleural metastasized angiosarcoma. Conclusion : The presence of hemoptysis or (recurrent) hemopneumothorax associated with cystic lung lesions should alert the clinician of possible pulmonary metastasized angiosarcoma.

Context: Trigger point injections (TPIs) and acupuncture are common procedures in management of chronic back pain and usually are considered safe. Needling into cervical and thoracic regions can be associated with life-threatening complications., Objective: The team intended to make practitioners aware of the potential for hemopneumothorax after TPI., Design: The research team describes a case of hemopneumothorax after TPI., Setting: The case study took place in the Department of Emergency Medicine at the Ankara University School of Medicine (Ankara, Turkey)., Participant: The participant was a 45-y-old woman, who had been admitted to the emergency department at the School of Medicine with dyspnea and dizziness after TPI for fibromyalgia., Results: Computerized tomography of the thorax showed a significant hemopneumothorax at the right hemithorax and a collapsed right lung, markedly in the right, lower lobe. The hemopneumothorax was successfully treated with chest-tube and video-assisted thoracoscopic surgery., Conclusions: Health care professionals need to be aware of hemopneumothorax when performing TPI on the chest wall.

Background: Pneumocephalus and pneumorachis, presence of air inside the skull and spinal canal, are mostly seen after neurosurgical procedures and neuraxial anesthesia. They have also been described after penetrating trauma, but never after blunt trauma without adjacent bone fractures., Case Description: We present the case of an 85-year-old white male patient admitted to our intensive care unit after a high velocity car accident. On site clinical evaluation showed normal consciousness with 15/15 Glasgow Coma Scale after a short initial loss of consciousness. The patient was first sent to a nearby hospital where a whole-body computed tomography scan revealed pneumocephalus and pneumorachis and an important left hemopneumothorax with pneumomediastinum with extensive subcutaneous emphysema. The state of the patient quickly worsened with hemorrhagic shock. The patient was sent to our intensive care unit; upon neurosurgical evaluation, no surgical indication was retained due to the absence of skull and spine fracture. A computed tomography scan performed on day 6 showed total regression of the pneumocephalus and pneumorachis. A follow-up computed tomography scan performed on day 30 revealed no intracranial bleeding or stroke, but a left pleural hernia between ribs 5 and 6. Due to respiratory complications, our patient could not be weaned from ventilator support for a proper neurological examination. Our patient's state finally worsened with septic shock due to ventilator-acquired pneumonia leading to multiple organ failure and our patient died on day 37., Conclusions: This is the first case report to describe pneumorachis and pneumocephalus following blunt trauma with pneumothorax, but no spinal or skull fractures. The mechanism that is probably involved here is a migration of air with subcutaneous emphysema and a pleural hernia into the spinal canal. However, in cases of pneumorachis or pneumocephalus, skull fractures need to be investigated as these require surgery and appropriate vaccination to prevent meningitis.

Background: Penetrating neck and chest trauma is a very common entity in emergency medicine that usually requires surgical treatment. Our case report illustrates the case of a 27-year-old Arabian man with hemopneumothorax associated with pneumomediastinum due to an unusual occupational injury., Case Presentation: A metal sliver, coming from an axe using for wood chopping, penetrated the neck of a 27-year-old Arabian man in the left supraclavicular region mimicking a gun bullet; the entrance hole was at the left pleural dome where the sliver had just penetrated the apex of the lung passing through the upper lobe of his left lung creating an exit wound in the dorsal segment of the same lobe arriving in the posterior thoracic wall. Biportal video-assisted thoracic surgery was performed to remove blood clots and the unusual foreign body.  CONCLUSION: In the literature, there are several case series about this topic, with some of them reporting unusual foreign bodies that lead to penetrating trauma. However, to the best of our knowledge, no cases like the one we have reported are described in the current literature.

A male infant with oesophageal atresia and distal tracheo-oesophageal fistula (TEF type C) underwent right thoracotomy and transpleural repair of TEF on day 4 of life. He did not have a family history of coagulation disorders. A preoperative finding of prolonged partial thromboplastin time (PTT)>200 s was overlooked, and he went to surgery. There were no concerns with haemostasis prior to and even during the operation. The prolonged PTT was treated with one 10 mL/kg dose of fresh frozen plasma in the immediate postoperative period. On the fourth postoperative day, the infant developed a right haemopneumothorax, requiring fresh frozen plasma and packed cell transfusions. He was subsequently diagnosed with severe haemophilia A due to intron 22 inversion in the factor VIII gene, with factor VIII level <0.01 IU/mL., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Spontaneous life-threatening hemopneumothorax is an atypical but treatable entity of unexpected circulatory collapse in young patients, affecting 0.5-11.6% of patients with primary spontaneous pneumothorax. Spontaneous pneumothorax is a well-documented disorder with a classic clinical presentation of acute onset chest pain and shortness of breath. This disorder might be complicated by the development of hemopneumothorax or tension pneumothorax., Case Presentation: A 23-year-old Asian man was referred to the emergency room of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. A physical examination revealed a young man who was awake and alert but in mild to moderate painful distress. His vital parameters were relatively stable at first. The examining physician noted slight tenderness along the right posterolateral chest wall along the eighth and tenth ribs. Primary spontaneous pneumothorax was considered, and a standing chest X-ray confirmed the diagnosis. A right thoracostomy tube was immediately placed under sterile conditions, and he was referred to the respiratory service. While in the respiratory department, approximately 420 mL of blood was drained from the thoracostomy tube over 15 minutes. Our patient developed obvious hemodynamic instability with hypovolemic shock and was subsequently admitted to the cardiothoracic surgical ward after fluid resuscitation. During the ensuing 4 hours after admission, 750 mL of blood was drained through the thoracostomy tube. A bedside chest X-ray was requested after he was temporarily hemodynamically stabilized. Primary spontaneous hemopneumothorax associated with right tension pneumothorax was considered based on the radiological impression and clinical signs. An emergency limited posterolateral thoracotomy was performed. A standing chest X-ray performed on day 6 of admission after the removal of the thoracostomy tube showed a complete re-expansion of his right lung. He remained stable and was discharged within 1 week., Conclusions: The successful treatment of a large spontaneous hemopneumothorax depends on early recognition, proactive intervention, and early consideration by a cardiothoracic surgeon. Once the diagnosis is confirmed, early thoracotomy should be considered. Such an aggressive surgery not only leads to shorter hospitalization but also confers better long-term outcomes.

This case study presents the inadvertent catheterization of a traumatic hemopneumothorax. A 22-year-old man sustained multiple stab wounds, including the left chest with a resultant hemopneumothorax. Upon arrival at a Level 1 trauma center, an ipsilateral subclavian central catheter was placed, blood was freely aspirated, and because of the patient's critical status, immediately utilized for resuscitation prior to line verification by radiography. A short time later, the catheter was felt to be malpositioned, most likely in the left intrathoracic space, and removed. The patient subsequently recovered and was discharged home 3 days later.

Background: The effectiveness of 14-French (14F) pigtail catheters (PCs) compared to 32-40F chest tubes (CTs) in patients with traumatic hemothorax (HTX) and hemopneumothorax (HPTX) is becoming more well known but still lacking. The aim of our study was to analyze our cumulative experience and outcomes with PCs in patients with traumatic HTX/HPTX. We hypothesized that PCs would be as effective as CTs., Methods: Using our PC database, we analyzed all trauma patients who required chest drainage for HTX/HPTX from 2008 to 2014. Primary outcomes of interest, comparing PCs to CTs, included initial drainage output in milliliters (mL), tube insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t test, Chi-square test, and Wilcoxon rank-sum test. We defined statistical significance as P < 0.05., Results: During the 7-year period, 496 trauma patients required chest drainage for traumatic HTX/HPTX: 307 by CTs and 189 by PCs. PC patients were older (52 ± 21 vs. 42 ± 19, P < 0.001), demonstrated a significantly higher occurrence of blunt trauma (86 vs. 55%, P ≤ 0.001), and had tubes placed in a non-emergent fashion (Day 1 [interquartile range (IQR) 1-3 days] for PC placement vs. Day 0 [IQR 0-1 days] for CT placement, P < 0.001). All primary outcomes of interest were similar, except that the initial drainage output for PCs was higher (425 mL [IQR 200-800 mL] vs. 300 mL [IQR 150-500], P < 0.001). Findings for subgroup analysis among emergent and non-emergent PC placement were also similar to CT placement., Conclusion: PCs had similar outcomes to CTs in terms of failure rate and tube insertion-related complications, and the initial drainage output from PCs was not inferior to that of CTs. The usage of PCs was, however, selective. A future multi-center study is needed to provide additional support and information for PC usage in traumatic HTX/HPTX.

Background: Tension pneumothorax is a cause of potentially preventable death in prehospital and battlefield settings and 14-gauge angiocatheter (14G AC) decompression remains the current treatment standard, despite its high incidence of failure. Traumatic pneumothorax is often associated with hemothorax, but 14G AC has no proven efficacy for associated hemothorax. We sought to compare the 14G AC to three alternative devices for treatment of tension hemopneumothorax (t-H/PTX) in a positive-pressure ventilation swine model., Methods: Our tension model was modified to incorporate a persistent air leak and pleural blood. Tension physiology was achieved with escalating carbon dioxide insufflation via transdiaphragmatic trocar, and 10% estimated blood volume was instilled into each chest. Intervention was randomized between 14G AC, 10-gauge angiocatheter (10G AC), modified Veress-type needle (mVN), and 3-mm laparoscopic trocar (LT). After recovery, serial tension-induced pulseless electrical activity (PEA) events were induced and decompressed. Success of rescue, time to rescue, and physiologic data were recorded., Results: One hundred ninety-five t-H/PTX and 88 PEA events were conducted in 25 swine. Laparoscopic trocar and 10G AC were more successful and had faster median time to rescue for t-H/PTX compared with 14G AC, whereas mVN performed comparably. Following PEA, 14G AC and mVN succeeded at rescue only 50% and 57% of the time, whereas 10G AC and LT had 100% success at return of spontaneous circulation. Time to successful return of circulation following PEA did not differ between devices; however, there was a noticeable difference in the rate of meaningful hemodynamic recovery following PEA favoring LT and 10G AC. There were no significant injuries noted., Conclusions: While mVN performed comparably to 14G AC, both have unacceptable failure rates. Ten-gauge AC and LT performed superiorly in both t-H/PTX and PEA. We believe there is now ample evidence supporting replacement of the 14G AC with 10G AC in current treatment recommendations.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Video of video-assisted thoracoscopic surgery (VATS) on a 16-year old who had been stabbed. The knife penetrated the diaphragm, lung and intercostal pedicle causing a haemopneumothorax. A chest drain was inserted by the trauma team. VATS was performed entirely through the stab and chest drain pre-existing wounds without extension., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We report 5 cases of penetrating chest wounds caused by weapons made from swordfish swords, involving breakage of the sword that later appeared as a thoracic foreign body. The patients had been assaulted 2 days to 17 years earlier. Three of them had a chronic infected wound, one had a penetrating thoracic wound with hemopneumothorax, and one had a foreign body. Computed tomography showed a foreign body in the lung in 4 cases, with aortic penetration in one. The foreign body was removed via thoracotomy in all 4 patients, with aorta repair in one who presented later with a pseudoaneurysm.

As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma., (2016.)

Traumatic pulmonary pseudocyst is uncommon and usually regresses spontaneously with conservative treatment. In rare cases, surgical intervention may be necessary. A pseudocyst may be treated surgically to prevent potential complications if the patient undergoes a thoracotomy for another reason. We present a patient with hemopneumothorax and traumatic pulmonary pseudocyst after a motor vehicle accident, who was operated on electively due to massive air leak., (© The Author(s) 2015.)

Introduction: Historical data suggests that many traumatic hemothoraces (HTX) can be managed expectantly without tube thoracostomy (TT) drainage. The purpose of this study was to identify predictors of TT, including whether the quantity of pleural blood predicted tube placement, and to evaluate outcomes associated with TT versus expected management (EM) of traumatic HTXs., Patients and Methods: A retrospective cohort study of all trauma patients with HTXs and an Injury Severity Score (ISS) ≥12 managed at a level I trauma centre between April 1, 2005 and December 31, 2012 was completed. Mixed-effects models with a subject-specific random intercept were used to identify independent risk factors for TT. Logistic and log-linear regression were used to compute odds ratios (ORs) for mortality and empyema and percent increases in length of hospital and intensive care unit stay between patients managed with TT versus EM, respectively., Results: A total of 635 patients with 749 HTXs were included in the study. Overall, 491 (66%) HTXs were drained while 258 (34%) were managed expectantly. Independent predictors of TT placement included concomitant ipsilateral flail chest [OR 3.03; 95% confidence interval (CI) 1.04-8.80; p=0.04] or pneumothorax (OR 6.19; 95% CI 1.79-21.5; p<0.01) and the size of the HTX (OR per 10cc increase 1.12; 95% CI 1.04-1.21; p<0.01). Although the adjusted odds of mortality were not significantly different between groups (OR 3.99; 95% CI 0.87-18.30; p=0.08), TT was associated with a 47.14% (95% CI, 25.57-69.71%; p<0.01) adjusted increase in hospital length of stay. Empyemas (n=29) only occurred among TT patients., Conclusions: Expectant management of traumatic HTX was associated with a shorter length of hospital stay, no empyemas, and no increase in mortality. Although EM of smaller HTXs may be safe, these findings must be confirmed by a large multi-centre cohort study and randomized controlled trials before they are used to guide practice., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

We experienced a case of a subtype of spontaneous hemopneumothorax caused by external forces associated with a seat-belt injury. A female aged 39 years sustained a minor collision with an oncoming car while she was driving. Although pneumothorax was not detected, hemothorax and bleeding from the area surrounding the subclavian artery were observed on contrast-enhanced chest computed tomography (CT). After confirming continuous bleeding into the thoracic cavity after superselective arterial embolization, we performed emergency open surgery. We found a bulla in the apex of the lung, and the thoracic stump of the bulla was considered the source of bleeding. In this case, the direct cause of hemothorax was considered to be the external force associated with the seat-belt injury. When a bulla in the apex of the lung and continuous bleeding are both observed on CT, spontaneous hemopneumothorax should be suspected, necessitating open chest surgery in cases where pneumothorax is not observed.

Current technique of airway management for impaled knife in the back includes putting the patient in lateral position and intubation. We present here a novel technique of anesthesia induction (intubation and central line insertion) in a patient with impaled knife in the back which is simple and easily reproducible. This technique can be used for single lung ventilation using double lumen tube or bronchial blocker also if desired.

Introduction: Routine chest radiography (CXR) following tube thoracostomy (TT) is a standard practice in most trauma centres worldwide. Evidence supporting this routine practice is lacking and the actual yield is unknown., Materials and Methods: We performed a retrospective review of 1042 patients over a 4-year period who had a routine post-insertion CXR performed in accordance with current ATLS® recommendations., Results: A total 1042 TTs were performed on 1004 patients. Ninety-one per cent of patients (913/1004) were males, and the median age for all patients was 24 years. Seventy-five per cent of all injuries (756/1004) were from penetrating trauma, and the remaining 25% (248/1004) were from blunt. The initial pathologies requiring TT were: haemopneumothorax: 34% (339/1042), haemothroax: 31% (314/1042), simple pneumothorax: 25% (256/1042), tension pneumothorax: 8% (77/1042) and open pneumothorax: 5% (54/1042). One hundred and three patients had TTs performed on clinical grounds alone without a pre-insertion CXR [Group A]. One hundred and ninety-one patients had a pre-insertion CXR but had persistent clinical concerns following insertion [Group B]. Seven hundred and ten patients had pre-insertion CXR but no clinical concerns following insertion [Group C]. Overall, 15% (152/1004) [9 from Group A, 111 from Group B and 32 from Group C] of all patients had their clinical management influenced as a direct result of the post-insertion CXR., Conclusions: Despite the widely accepted practice of routine CXR following tube thoracostomy, the yield is relatively low. In many cases, good clinical examination post tube insertion will provide warnings as to whether problems are likely to result. However, in the more rural setting, and in resource challenged environments, there is a relatively high yield from the CXR, which alters management. Further prospective studies are needed to establish or refute the role of the existing ATLS® guidelines in these specific environments., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Emergency management of spontaneous hemopneumothorax patients was retrospectively analysed in this study. From November 2009 to August 2012, 221 patients with spontaneous pneumothorax were treated in the thoracic surgery clinic. Among them, 9 (4.07%) were diagnosed with spontaneous hemopneumothorax. Chest X-ray and computed tomography were the diagnostic tools. Emergency thoracotomy was performed for 7 of 9 patients because of massive hemothorax and continuous bleeding from the chest tube. Massive hematoma was documented in 2 of 7 patients at tomography. Bridging veins and torn pleural adhesion between parietal and visceral pleura were the source of bleeding determined at thoracotomy. Hematoma evacuation, resection of bullae, ligation of pleural adhesions and apical pleurectomy were performed. Spontaneous hemopneumothorax is an emergency due to massive hemorrhage and hematoma formation. Early surgical treatment is recommended for patients with spontaneous hemopneumothorax.

Velpeau bandage is a treatment method that fixes the arm to the body in cases of fractures and dislocations at the region of shoulder. Velpeau bandage very rarely leads to complications. This case report involves a 45-year-old male admitted to the emergency service after trauma. Glenoid and multiple rib fractures were detected in radiological examinations. A transient Velpeau bandage was performed before surgical correction. Patient had dyspnea and chest pain 24 hours after bandage application. An obvious displacement at the rib fracture sites and hemopneumothorax were seen in the chest X-ray. A chest tube was inserted into the patient. Glenoid fracture was corrected surgically. Patient was discharged on the sixth day. He has no problems at readmission after the first month.

Objective: To investigate the therapeutic effect of total en bloc spondylectomy (TES) for thoracolumbar tumors and the results of spinal stability reconstruction., Methods: From January 2007 to June 2011 there were 18 patients with thoracolumbar tumors distributed in the thoracic vertebrae (n = 10) and lumbar vertebrae (n = 8). There were 7 haemangiomas, 5 giant cell tumors of bone, 1 malignant schwannoma, 1 solitary plasmocytoma, 1 neuroblastoma, 1 osteoblastoma, 1 metastatic malignant fibrous histiocytoma, and 1 metastasis of breast cancer. All the 18 patients were treated with improved TES under electrophysiological monitoring of spinal cord. Four patients were treated through one-stage combined anteroposterior approach and 14 patients through one-stage posterior approach. The anterior reconstructions included titanium mesh cages filled with bone or bone cement in 15 cases, titanium mesh cage with strengthened rings in 2 cases and artificial vertebral body replacement in 1 case. The posterior reconstruction included multiple segmental fixation with pedicle screw-rod system in 15 cases and short segmental fixation in 3 cases. Massive bone auto-graft was employed in 13 cases and fragmental bone graft in 5 cases., Results: The total en bloc spondylectomy was performed successfully in 15 patients and unsuccessful in 3 whose spinal tumors were resected by piecemeal technique. In 15 patients with successfully performed TES, the duration of surgery was from 340 to 610 min (average, 450.7 min), the blood loss was from 3000 to 10 200 ml (average, 4850 ml), and the intraoperative blood transfusion was from 2800 to 9600 ml (average, 4200 ml). The operation-related complications comprised hemopneumothorax, intercostal nerve pain, stress ulcer and bleeding, and so on. One year after operation, the patients with neurological dysfunction recovered from grade A to grade D in one patient, and to grade E in the other 14 cases. The average visual analog scale (VAS) scores was 0.5. One patient with plasmacytoma and another one with L5 metastatic tumor suffered progression of the disease and were living with the diseases. The patient with metastatic malignant fibrous histiocytoma died of local recurrence and lung metastasis 16 months postoperatively. One patient with L4 neuroblastoma died of other reason and all the rest were free from relapse. The Cobb angle of upper and lower vertebral body adjacent to the involved vertebrae in sagittal plane was from -26.7° to 12.0° (average, -2.57°) just postoperatively and from -17.5° to 57.2° (average, 11.5°) at the last follow-up or before reoperation. There were 2 patients with screw-rod breakdown and 2 patients with internal fixation loosening. The measurement of titanium mesh cage subsided into adjacent vertebral bodies was average 7.5 mm. The revision surgery was performed in 3 patients, through combined anteroposterior approach in 2 and only posterior approach in 1 patient., Conclusions: TES significantly increases the therapeutic effect of spinal tumors, although accompanied with high difficulty and massive bleeding. In spinal stability reconstruction after total spondylectomy, it should be emphasized that posterior long segment fixation with pedicle screw-rod system, massive bone bridging graft and the application of thoracolumbosacral orthosis can achieve short-term firm fixation and long-term fusion-stabilization.

Background: Antibiotic use in injured patients requiring tube thoracostomy (TT) to reduce the incidence of empyema and pneumonia remains a controversial practice. In 1998, the Eastern Association for the Surgery of Trauma (EAST) developed and published practice management guidelines for the use of presumptive antibiotics in TT for patients who sustained a traumatic hemopneumothorax. The Practice Management Guidelines Committee of EAST has updated the 1998 guidelines to reflect current literature and practice., Methods: A systematic literature review was performed to include prospective and retrospective studies from 1997 to 2011, excluding those studies published in the previous guideline. Case reports, letters to the editor, and review articles were excluded. Ten acute care surgeons and one statistician/epidemiologist reviewed the articles under consideration, and the EAST primer was used to grade the evidence., Results: Of the 98 articles identified, seven were selected as meeting criteria for review. Two questions regarding presumptive antibiotic use in TT for traumatic hemopneumothorax were addressed: (1) Do presumptive antibiotics reduce the incidence of empyema or pneumonia? And if true, (2) What is the optimal duration of antibiotic prophylaxis?, Conclusion: Routine presumptive antibiotic use to reduce the incidence of empyema and pneumonia in TT for traumatic hemopneumothorax is controversial; however, there is insufficient published evidence to support any recommendation either for or against this practice.

Unlabelled: The aim of the paper is to observe the effectiveness of prophylactic administration of antibacterials against empyema and pneumonia after tube thoracostomy for traumatic collections., Material and Methods: Observational retrospective study over a ten years period (2002-2011), at the Oradea County Emergency Hospital on 939 patients with chest tube drainage for traumatic haemo/pneumothoraces. The morbidity by intrathoracic infections was 5,5% in the curative antibiotic group., Results: The median number of risk factors for surgical infections and case severity were not statistically different (p=0.9653 and p=0,6601) between cases with antibioprophylaxis and curative treatment, but the incidence of intrathoracic infection in the prophylaxis group (n=86) was half (2,3%). Antibioprophylaxis was effective in over 95% of the cases and it associated in-hospital length of stay, length of stay in the ICU and costs of care significantly (p<0.0001, p<0.0001, p=0.0046) lesser than of those patients treated with curative regimen. The overall mortality was 8.6% within the curative regimen group with an attributable mortality to infections of 17.39%; but it was only 2.3% and respectively 0 within the prophylaxis group., Conclusions: Antibiotic prophylaxis for intrathoracic infections after tube thoracostomy for traumatic collections was justified by case severity and risk factors and was effective and cost-efficient, but it should be administered selectively.

Spontaneous hemo-pneumothorax is one of the pulmonary complications of connective tissue disorders such as Ehlers-Danlos syndrome (EDS). Most thoracic surgeons overlook this fact and they consider it as primary. In the following report, we describe a unique case of spontaneous recurrent hemo-pneumothorax in a young patient with undiagnosed EDS. The aim of this presentation is to raise a high index of suspicion of every thoracic surgeon to include in his differential diagnosis, the connective tissue disorders in any case of spontaneous hemo-pneumothorax.

One case of traumatic forequarter amputation associated acute lung injury (ALI) was presented. A discussion reviewing the treatment guidelines for this devastating injury, and pointing out the importance of supporting the lung and preventing the development of acute respiratory distress syndrome (ARDS) was included.

Spontaneous hemopneumothorax is a rare, potentially life-threatening condition occurring in adolescence. In general, spontaneous hemopneumothorax has not been associated with other pulmonary vascular malformations in adolescents. We present a case of a 17-year-old adolescent boy with hemopneumothorax from vascularized pleural blebs who was also noted to have a pulmonary hemangioma., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Hemopneumothorax is a common sequelae of traumatic thoracic injury. The most effective treatment of this condition is thoracic drainage. Despite the common occurrence of this condition, available instruments are difficult to use emergently, particularly when large amounts of patients need to be drained. In the present experiment, a newly designed chest tube and thoracic closed drainage package is described and preliminarily evaluated with the goal to improve the treatment of traumatic hemopneumothorax., Method: Twenty canines were divided into two groups. In one group, the newly designed thoracic closed drainage package was used, whereas in the other group a currently available chest tube and bottle were used. Drainage test, ultrasound examination, flushing test, and tension test were performed to evaluate the effectiveness of the drainage package., Results: We found that the newly-designed drainage tube is as effective as the common tube when evaluated using all of the chosen methods. In addition, the package is very lightweight and portable., Conclusion: The newly-designed thoracic drainage package is very effective in the emergency treatment of thoracic trauma and may be more suitable for the emergency treatment of hemopneumothorax.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a safe and effective technique for the sampling of mediastinal and hilar adenopathies. We describe the first reported case of pulmonary artery intramural hematoma after EBUS-TBNA puncture of this artery. The complication was visualized by ultrasound and resolved spontaneously., (Copyright © 2011 S. Karger AG, Basel.)