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Eur J Cardiothorac Surg 2004;25:859-864
© 2004 Elsevier Science NL

A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma

P. Misthos*, S. Kakaris, E. Sepsas, K. Athanassiadi, I. Skottis

1st Thoracic Surgical Department, General Hospital for Chest Diseases ‘SOTIRIA’, Athens, Greece

Received 7 October 2003; received in revised form 26 January 2004; accepted 29 January 2004.

* Corresponding author. Address: 7 P. Dimitrakopoulou Street, 11141 Athens, Greece. Tel./fax: +30-210-252-9048
e-mail: panmisthos{at}yahoo.gr


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Objectives: A prospective analysis was conducted to define the incidence of occult pneumothorax (OPX), delayed pneumothorax (DPX) and delayed hemothorax (DHX) and to propose an algorithm for surveillance. Methods: During the last 2 years 709 consecutive patients who did not fulfill the indications for intrahospital management were examined at our emergency department for blunt thoracic injury. All patients were subjected to expiration posteroanterior chest radiograph (eCXR) and were scheduled for reevaluation after 24, 48 h and at 7, 14 and 21 days. Results: OPX was present in 28 patients (4%) detected only with eCXR on admission, 14 patients developed DPX (2%) at 24–48 h later, and 52 patients presented up to 14 days later with DHX (7.4%). Of all DHX 42 (80.7%) required chest tube drainage, eight thoracentesis (16%) and only two (4%) were subjected after 1 month to decortication. No related morbidity was recorded. All the patients with the DHX had at least one rib fractured. Only one death among the DHX patients was documented. Conclusions: A safe algorithm is recommended: eCXR for every patient who suffered blunt thoracic injury with at least one rib fracture detected and is treated as an outpatient or in case his/her compliance with the reevaluation schedule will be suboptimal. Close follow-up is also suggested since these entities do exist, cannot be ignored and their treatment is early evacuation of the pleura cavity.

Key Words: Blunt thoracic trauma • Occult pneumothorax • Delayed hemothorax


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Blunt chest trauma is a frequent cause for thoracic surgical consultation at the emergency department. It comprises 70% of all thoracic injuries [1,2]. Clinical examination along with chest imaging is often sufficient for diagnosis and proper treatment [3,4]. Since thoracic trauma has a high mortality rate (20–25% of all trauma deaths) overlooked chest injuries carry serious consequences [2]. In order to examine the accuracy of our diagnostic tools in patients with blunt thoracic trauma, who are treated on an outpatient basis, the authors conducted a prospective study to define the incidence and type of undetected injuries such as occult pneumothorax (OPX), delayed pneumothorax (DPX) and delayed hemothorax (DHX) and to suggest an algorithm for surveillance.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
From July 2001 through July 2003, 1114 consecutive patients were admitted at the emergency department for thoracic surgical consultation. The indications for intrahospital management were fulfilled in 288 patients (25.8%). The criteria for outpatient management were: two or less rib fractures, age less than 65 years, no lung parenchyma injury, no other system injury and absence of any concomitant or comorbid diseases.

Minor blunt chest trauma includes all the cases of chest injury where the lesions are confined to minor chest wall injury (abrasions, muscle contusion, echymoses) with no more than two rib fractures and without flail chest, lung, heart or other mediastinal organ injury in an otherwise healthy person. Moreover, no other system injury must be detected.

Although 826 patients (74.2%) were discharged to be managed as outpatients, only 709 (63.6%) were included in the study group, because the rest 117 either did not comply with our follow-up schedule or never entered that schedule because no chest involvement at the accident was detected or were injured longer than 24 h before admission or finally OPX was diagnosed at abdominal CT scan.

After clinical examination all patients were ordinarily subjected to upright posteroanterior, lateral and expiration posteroanterior chest radiograph (eCXR) and to arterial blood gases analysis. Besides they were scheduled for reevaluation after 8, 24, 48 h and, if nothing was noted, at 7, 14 and 21 days. Depending on clinical findings or even suspicion the follow-up was modified according to the clinical situation encountered. All patients were discharged on analgesic and mucolytic treatment.

All cases with OPX, DPX and DHX were recorded and analyzed. OPX was defined as the pneumothorax, which was not detected on routine upright inspiration CXR but only as subtle pleural air collection detected on expiration CXR or at thoracic/abdominal CT scan. OPX detected only at abdominal CT scanning, despite normal chest radiology, was excluded. DPX was defined as the pneumothorax not clinically or radiologically detected upon admission, not even evident at eCXR but detected on routine CXR later. The size of a pneumothorax (PNX) was calculated through a nomogram, by using the sum of three roentgenographic measurements divided by three: the maximal interpleural distances between the visceral and parietal pleura at the apex, middle upper and lower half of the thorax in the frontal plane [5,6]. DHX was defined as blood collection in the pleural space that becomes clinically or radiologically evident one or more days later despite normal CXRs upon admission.

Age, gender, type and severity of injury, mechanism of injury, interval from the incident to diagnosis or presentation, associated thoracic injuries, treatment modality employed and mortality rate of patients who developed OPX, DPX or DHX were recorded, in order to define their incidence and recommend an algorithm for surveillance. Indications for CT scanning during follow-up were undiagnosed lung field opacities, suspicious diaphragm configuration and identification of the hemothorax source.

Patients injured longer than 24 h before admission were excluded from the study.

Treatment protocol included: (a) For a PNX, if the estimated size was less than 15% expectant policy was employed, if 15–30% thoracentesis was conducted and if larger than 30% chest tube thoracostomy was performed [5]. In case PNX recurred in less than 6 h after thoracentesis, chest tube thoracostomy was performed too. (b) For a HMX, if the estimated blood amount was less than 300–400 ml thoracentesis was performed, whereas if larger than 500 ml chest tube thoracostomy was employed. The amount of pleural effusion was estimated by the upright CXR: if the collection just filled the ipsilateral costophrenic angle the amount was calculated to 300–400 ml, whereas any larger effusion was estimated as more than 500 ml. The indications for surgical management of HMX was continuing bleeding (more than 200 ml for 4 h) or clot formation and lung entrapment or empyema thoracis development.


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 Appendix A. Conference...
 References
 
The total number of patients studied was 709. This group included 471 men (66.4%) and 238 women (33.6%) whose age ranged from 17 to 91 years (mean 58 years). The characteristics of this group is described in Table 1.


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  		Table 1. Minor blunt chest trauma group characteristics

 
OPX was encountered in 28 patients (4%) (Table 2). The most frequent associated thoracic injury was chest wall muscle contusion (78.6%), followed by no other injury or minor cutaneous trauma (46.4 and 17.8%, respectively). Surprisingly, rib fractures were found in only a small percentage of cases (10.8%). Expectant management was the initial treatment of all OPX. Expectant management was employed in nine (32%) patients, with a successful outcome in eight of them (88.8%), whereas one patient needed thoracentesis. Among the 16 (57.1%) patients subjected to thoracentesis 13 (46.4%) patients were successfully treated (81.25%). All seven patients (25%) managed with chest tube thoracostomy had an excellent outcome. No mortality was recorded in this group during the first posttraumatic month. No surgical management was needed.


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  		Table 2. Occult and delayed pneumothorax characteristics

 
DPX was detected in 14 patients (2%) (Table 2). The most frequent associated injury with DPX was found to be one or two rib fractures (50%) that might have a causative relationship with DPX. In 35.7% no other thoracic posttraumatic lesion was found. The most frequent injury mechanism were fall in 50% of cases (mostly to the ground or not more than 2 m height) and sports' accidents (21.4%). In both OPX and DPX cases, right side was observed to be predominant (71%), a fact without any clinical implication. In the DPX group no deaths were recorded during the first posttraumatic month. No surgical management was needed.

DHX proved to be a much more common incident (Table 3). Fifty-two patients (7.4%) presented up to 14 days after injury with delayed pleural blood collections despite the normal clinical and radiologic findings during the first 36 posttraumatic hours. The diagnosis of DHX was set 2–14 days (mean 7.32 days) later (Table 4). At least one rib fracture was detected in the patients with DHX (65.4% with one rib fracture and 34.6% with two). Motor vehicle accidents and pedestrians ones proved to be the major injury mechanism (80.9%). Twelve patients were managed with thoracentesis (23%). The success rate was 66.6% (8 patients), while four patients were further managed with chest tube thoracostomy. Forty-four patients (84.6%) were finally subjected to chest tube thoracostomy. It was successful in 41 patients (93.2%). Two patients (3.9%) were subjected to thoracotomy due to ongoing hemorrhage and clot formation, which needed decortication. One patient (1.9%) died 18 days after the accident due to intercostal artery bleeding because of thrombus lysis.


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  		Table 3. Delayed posttraumatic hemothorax characteristics

 

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  		Table 4. Time of diagnosis

 
DPX was detected during the first 2 days (peak within the first day, i.e. 78.5%) and DHX was most frequently diagnosed on the seventh day (78.8%) (Table 4). The latest follow-up was the 21st day. No patient after that period returned to the hospital with DPX or DHX.

CT scans were conducted in 191 patients (26.9%) mostly after motor vehicle accidents (126 patients, 66%). CT scan diagnosis contributed in only one case (0.9%), where DPX was detected. No other traumatic lesion (e.g. diaphragmatic rupture, mediastinal injury, vascular injury, etc.) was found.

Analysis of associated injuries and mechanism of injury in each entity did not reveal any reliable prognostic factor, but a strong correlation between rib fractures and DHX. Among all motor vehicle and fall accidents only 20 (3.2%) led to OPX and among those with chest wall muscle contusion only 22 (3.6%) developed OPX (Tables 1 and 2). DPX was described in 10 patients after fall or sports' accidents (2.2%). It is important to mention that in 10 cases out of 42 OPX and DPX (23.8%) no other injury was traced except ipsilateral subtle chest discomfort at the end of deep inspiration. However, in 18.9% of all patients classified with no associated chest injury, OPX or DPX was detected (Tables 1 and 2). DHX was more frequently observed after motor vehicle collisions or pedestrian accidents (80.9%), while only 5.2% of such accidents developed DHX (Tables 1 and 3). At least one rib fracture was present when DHX was developed. Fifty-two patients out of 406 with rib fractures developed DHX (12.8%).

The 2-week follow-up algorithm was modified only in the 66 cases (9.3%) of DPX and DHX, since the process of the injury determined the subsequent follow-up.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
Appendix A. Conference...
 References
 
Although several reports have been published reviewing delayed presentation or missed diagnosis of injuries associated with blunt thoracic trauma [3,7,8], OPX, DPX and DHX have been scarcely studied in the literature [9–12]. Moreover, most of these studies were retrospective ones and no collective prospective study is within our knowledge concerning these entities after minor blunt thoracic trauma. The incidence of OPX, DPX and DHX proved to be 4, 2 and 7.4%, respectively. These findings are in accordance with previous series [11–17]. These figures showed that these entities should be anticipated.

The suggested mechanism is common in both OPX and DPX. We believe that lung parenchyma rupture was mostly due to valsava mechanism in OPX cases along with laceration caused from a rib fracture in DPX cases. The air leak was so small that no air collection was detected on the initial inspiration CXR. Among the 42 patients who developed a posttraumatic air leak, in 28 (66.6%) the detection was possible at admission with eCXR. According to the above-mentioned observations, we recommend expiration chest radiograph upon admission for every patient with blunt chest injury since no prognostic factor was found to predict which patient would develop pneumothorax and since eCXR detected the majority of air leaks during the first thoracic surgical involvement. It is our belief that eCXR turned out to be a very helpful diagnostic tool along with routine examination especially for patients on an outpatient basis.

Although CT scan proved to be a significant diagnostic tool for exclusion after ambiguous clinical and radiographic findings, it did not offer any contribution (only 0.9%) to the detection of these lesions [2,11,15,16]. Consequently, CXR including eCXR on admission is sufficient for the follow-up of these patients. Since only CXR is needed, the suggested algorithm is easily conducted and is also cost-effective. CXR use leads to 90 euros cost, while CT scan use would increase expenses up to 145 euros.

As far the mechanism of injury is concerned, the small incidence of these entities cannot constitute any mode of accident to be prognostic for the type of pleural disease that will be developed. However, there are some points to be taken under consideration: (a) DHX was detected mostly after motor vehicle collisions or pedestrian accidents (80.9%) but of all these accidents only 5.2% developed DHX; (b) motor vehicle collisions along with falls were the most common accidents for OPX, while only 3.2% of such incidents caused subclinical pneumothorax; (c) fall was the most frequent mechanism for DPX (50%). Only 1.6% of all falls developed DPX.

Two conclusions from the associated injuries analysis deserve to be noted: (a) all DHX are related to at least one rib fracture (65.4% one rib and 34.6% two ribs fractured). The incidence of DHX among all rib fractures recorded was 12.8% and that should be taken under consideration for minor blunt chest trauma decision-making. Rib fractures were easily diagnosed on CXR. Moreover, they were the main cause of bleeding in the pleural space; (b) in 23.8% of patients who developed either OPX or DPX no other associated injury was diagnosed. However, a pneumothorax was developed in 18.9% of all cases in whom no injury was detected.

Available treatment modalities can be summarized in four categories: expectant management, thoracentesis, chest tube thoracostomy and surgical treatment [5,13,18–22]. In case of OPX/DPX chest tube thoracostomy was performed in 25–28%, which is in accordance with previous reports [17,18,21,23]. In case of DHX the major goal of management was immediate evacuation of pleural space in order that serious complications can be avoided [24]. The earlier the detection of hemothorax and the sooner the pleural drainage, the better the patients' outcome.

The authors suggest that blunt chest injury, even when not initially serious, might hide a lot of perils for patient's life and surgeon's reputation. Therefore, a routine follow-up for all patients is recommended irrespectively of the severity of initial findings.

No prognostic factor was detected in order to classify patients in different follow-up algorithms. All patients who do not fulfill the criteria for intrahospital management after minor blunt chest trauma should be closely followed for at least 2 weeks after the accident. This is supported by the facts that OPX, DPX and DHX should be anticipated, cannot be predicted and have excellent prognosis if detected in time. In conclusion, patients who suffered minor blunt thoracic injury should be closely screened for OPX, DPX and DHX. In case, they are treated as outpatients the authors recommend a feasible and cost-effective follow-up algorithm: Every patient who will be managed on an outpatient basis should be subjected to expiration chest radiograph upon admission and scheduled to a strict follow-up timetable that extends up to 2 weeks, which will include clinical and radiographic check-up even if no pathologic findings are recorded at initial examination on admission or at intermediate examinations.


   Footnotes
 
Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.


   Appendix A. Conference discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
References
 
Dr T. Ferguson (St. Louis, MI, USA): I think the take-home message here is very important, particularly for emergency units that see patients and send them home without follow-up. At least that happens in our country.

Dr M. Ahmed (Khartoum, Sudan): In your method, apart from the chest X-ray, you suggested that you have to do arterial blood gases. Are you expecting for occult pneumothorax taking arterial blood gases, and what are the findings of your arterial blood gases?

Dr Misthos: Well, in our department and the emergency department at our hospital, arterial blood gas evaluation for every patient with blunt chest trauma is a routine examination to evaluate the baseline for pulmonary function. I mean one of the parameters to decide which possible treatment modality will follow has to do with the underlying pulmonary function. I mean with a patient with COPD, you won't do thoracentesis or observe a pneumothorax, but we think that you should insert a chest tube. So there was no statistical difference between any groups of arterial blood gases. It was just a routine examination.

Dr G. DiRienzo (Bari, Italy): When faced with chest trauma with stable patients with a modest hemothorax, and you showed some surgical treatment, essentially chest drainage positioning, what is your strategy in these patients? Do you perform a video-thoracoscopic access or do you just place a chest drainage?

Dr Misthos: It has to do with a combination of time and amount of blood collection. I mean if it's a large hemothorax, we very cautiously begin with videoscopic treatment, but actually we have in mind the case of an open thoracotomy. If it is a moderate or a small hemothorax and it is very early, I mean not more than 3 or 4 days, we begin with thoracentesis. We have observed that there is a very low percentage of recurrence and, of course, you avoid general anesthesia. If there is recurrence, then we proceed to VATS, video-thoracoscopic evacuation.

Dr DiRienzo: You don't use the VATS procedure under local anesthesia to correctly place the drainage, to look at the situation in the pleural cavity, and also for a safe drainage?

Dr Misthos: No, no.

Dr I. Cordos (Bucharest, Romania): It's uncommon that chest trauma with less percent of rib fractures has so high a percent of pneumothorax. How can you explain it?

Dr Misthos: Valsava mechanism. This is the only mechanism we do suggest.

Dr Cordos: Have you studied another disease of the lung, chronic obstruction or another disease of the lung that can explain a pneumothorax in this type of patient?

Dr Misthos: You mean if there was chronic obstructive disease?

Dr Cordos: Yes another lung disease, chronic lung disease.

Dr Misthos: Nothing statistically significant, no.

Dr R. Jakovic (Belgrade, Yugoslavia): Concerning rib fractures, did you analyze the status of the underlying lung tissue at the first examination? What was the status of the lung tissue concerning rib fracture?

Dr Misthos: Do you mean whether there's lung laceration?

Dr Jakovic: Did you realize or did you reveal any contusion of the lung on the first X-ray?

Dr Misthos: Yes, I see what you mean. From CT scans, there was not a statistically significant difference from any other group. Possibly it's our opinion that there should be a laceration. I mean there is a causative relation between the rib fractures and either pneumothorax or hemothorax through laceration.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 

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