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A 56-Year-Old Woman With a Recurrent Pleural Effusion After Chest Trauma FREE TO VIEW

Tomás Francisco Fariña González, MD; Antonio Núñez Reiz, MD; Julieta Latorre, MD; Martín Salcedo Rivas, MD; Eduardo Morales Sorribas, MD
Author and Funding Information

aDepartment of Critical Care, Hospital Universitario Clinico San Carlos, Madrid, Spain

bDepartment of Anaesthesiology, Hospital Universitario La Paz, Madrid, Spain

CORRESPONDENCE TO: Tomás Francisco Fariña González, MD, Department of Critical Care, Hospital Universitario Clinico San Carlos, Madrid, Spain


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(2):e33-e35. doi:10.1016/j.chest.2016.02.690
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Published online

A 56-year-old woman was transferred to the ED after high-energy thoracic trauma with multiple bilateral rib fractures resulting from a car accident. Because of bilateral hemopneumothorax, bilateral chest tubes were placed and mechanical ventilation was started. As the patient recovered, weaning from mechanical ventilation was initiated. Drainage stopped and chest tubes were removed a few days later. During a weaning trial, a severe flail chest that impaired respiratory efforts became apparent. Surgical stabilization of the chest cage was made with titanium clips. Finally, the patient was successfully weaned from the ventilator. Ten days later, respiratory failure gradually developed. On physical examination, no crepitation or collection was found near the surgical incision. On the auscultation of the left hemithorax, breath sounds were absent. A chest radiograph study showed opacification of the left hemithorax (Fig 1). Further evaluation with chest ultrasonography (US) was performed (Video 1).

Figure Jump LinkFigure 1 Chest radiography obtained with complete opacification of the left hemithorax. Titanium clips and surgical staples can also be seen.Grahic Jump Location

Question: Which findings would you expect to be revealed by the chest US in this trauma patient?

Answer: We would expect to find a left pleural effusion with compressive atelectasis.

Bedside thoracic US found a large heterogeneous left pleural effusion with compressive atelectasis of the ipsilateral lung (Video 1). Furthermore, a hypoechogenic collection was located outside the rib cage at the fifth to sixth intercostal spaces in the anterior axillary line, 5 cm from the surgical scar. Between the extrapleural collection and the pleural space, a to and fro motion in synchrony with respiration was observed on color flow examination and a valve mechanism was detected (Videos 2 and 3). On inspiration, fluid entered the pleural space; on expiration, it left it. To clarify these findings, a thoracic CT scan was performed, which showed the collection outside the rib cage and the connection between it and the pleural space (Fig 2). A left chest tube for drainage was placed and 1,500 mL of serohematic fluid was obtained, with improvement in the patient’s condition. A new thoracic US was performed with only a minimal pleural effusion that remained. A pleural line image appeared in the area where the orifice was previously detected and the to and fro Doppler signal disappeared in the color Doppler study.

Figure 2
Figure Jump LinkFigure 2 Thoracic computed tomography showing a collection outside the rib cage and the connection between it and the pleural space.Grahic Jump Location

Our hypothesis is that this patient suffered low-flow bleeding from the chest wall hematoma to the pleural space (Video 4, Discussion video). Because of the variations in pleural pressures during the ventilation cycle and, possibly, the “squeezing” of the extrapleural collection by the intercostal muscles, fluid was displaced into the pleural cavity during inspiration (Video 2: blue color). During exhalation, retrograde flow (Video 2: red-yellowish color) took place, but was limited by a small portion of parietal pleura acting like a valve, almost closing the communication between both spaces and avoiding coagulation or reabsorption of both effusions. After removing the pleural fluid, the lung sealed the foramen and the valve mechanism disappeared.

Extrapleural hematomas are a rare complication of blunt thoracic trauma and, although not reported, they might be associated with thoracic surgery as well. Medical references in literature about traumatic recurrent hemothorax are scarce. Delayed hemothorax after blunt thoracic trauma is a better known entity. In a retrospective review of 36 patients with hemothorax consequent to blunt trauma, 4 required surgical intervention. Pleural lacerations were found in these cases and torn intercostal arteries were the presumed cause of bleeding. No extrapleural collections were reported. In a Japanese case report, a communication between pleural space and chest wall collection as a cause of delayed hemothorax has been previously described.

Diagnostic accuracy of US in the acute assessment of common thoracic lesions after trauma has been evaluated,, but there are few reports about its utility in clarifying the origin of pleural effusions. Compared with CT, thoracic US might have better diagnostic performance in certain pleural diseases. A study that compared CT and US in unilateral hemithorax opacification showed that US was able to find six lesions that CT failed to locate, including four focal pleural thickenings. A similar sign to ours (the “fluid color sign”) was described by Wu and colleagues and was proposed to differentiate between anechoic pleural thickening and effusion (89.2% sensitivity, 100% specificity).

Color Doppler modes are currently used to evaluate different lung and pleural lesions,, but there are no reports about its use in trauma patients. This is, to our knowledge, the first report of the color Doppler pattern of a communication between pleural space and extrapleural tissues and of the ventilation-synchronous valve mechanism linking them. This case enhances the importance and usefulness of pleuropulmonary US in trauma evaluation and in understanding pathophysiology of thoracic diseases.

  • 1.

    Chest ultrasonography is helpful in assessing the mechanism of genesis and perpetuation of trauma-related pleural effusions.

  • 2.

    Chest ultrasonography can identify collections that are sometimes difficult to detect with other imaging techniques.

  • 3.

    Not only B-mode ultrasonography can be used when performing a chest ultrasonography evaluation; Doppler techniques are also useful in evaluating different lung and pleural entities, including trauma-related lesions.

Financial/nonfinancial disclosures: None declared.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Chung J.H. .Carr R.B. .Stern E.J. . Extrapleural hematomas: imaging appearance, classification, and clinical significance. J Thorac Imaging. 2011;26:218-223 [PubMed]journal. [CrossRef] [PubMed]
 
Taylor B.C. .French B.G. . Successful treatment of a recalcitrant pleural effusion with rib fracture fixation. HSSJ. 2013;9:96-99 [PubMed]journal. [CrossRef]
 
Simon B.J. .Chu Q. .Emhoff T.A. .Fiallo V.M. .Lee K.F. . Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity. J Trauma. 1998;45:673-676 [PubMed]journal. [PubMed]
 
Masuda R. .Ikoma Y. .Oiwa K. .Nakazato K. .Takeichi H. .Iwazaki M. . Delayed hemothorax superimposed on extrapleural hematoma after blunt chest injury: a case report. Tokai J Exp Clin Med. 2013;38:97-102 [PubMed]journal. [PubMed]
 
Hyacinthe A.C. .Broux C. .Francony G. .et al Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma. Chest. 2012;141:1177-1183 [PubMed]journal. [CrossRef] [PubMed]
 
Mathis G. .Blank W. . The chest wall.Mathis G.. Chest Sonography.  :- [PubMed]journal
 
Yu C.J. .Yang P.C. .Wu H.D. .Chang D.B. .Kuo S.H. .Luh K.T. . Ultrasound study in unilateral hemithorax opacification. Image comparison with computed tomography. Am Rev Respir Dis. 1993;147:430-434 [PubMed]journal. [CrossRef] [PubMed]
 
Wu R.G. .Yang P.C. .Kuo S.H. .Luh K.T. . “Fluid color” sign: a useful indicator for discrimination between pleural thickening and pleural effusion. J Ultrasound Med. 1995;14:767-769 [PubMed]journal. [PubMed]
 
Görg C. .Bert T. . Transcutaneous colour Doppler sonography of lung consolidations: review and pictorial essay. Part 1: pathophysiologic and colour Doppler sonographic basics of pulmonary vascularity. Ultraschall Med. 2004;25:221-226 [PubMed]journal. [CrossRef] [PubMed]
 
Görg C. .Bert T. . Transcutaneous colour Doppler sonography of lung consolidations: review and pictorial essay. Part 2: colour Doppler sonographic patterns of pulmonary consolidations. Ultraschall Med. 2004;25:285-291 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 Chest radiography obtained with complete opacification of the left hemithorax. Titanium clips and surgical staples can also be seen.Grahic Jump Location
Figure Jump LinkFigure 2 Thoracic computed tomography showing a collection outside the rib cage and the connection between it and the pleural space.Grahic Jump Location

Tables

References

Chung J.H. .Carr R.B. .Stern E.J. . Extrapleural hematomas: imaging appearance, classification, and clinical significance. J Thorac Imaging. 2011;26:218-223 [PubMed]journal. [CrossRef] [PubMed]
 
Taylor B.C. .French B.G. . Successful treatment of a recalcitrant pleural effusion with rib fracture fixation. HSSJ. 2013;9:96-99 [PubMed]journal. [CrossRef]
 
Simon B.J. .Chu Q. .Emhoff T.A. .Fiallo V.M. .Lee K.F. . Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity. J Trauma. 1998;45:673-676 [PubMed]journal. [PubMed]
 
Masuda R. .Ikoma Y. .Oiwa K. .Nakazato K. .Takeichi H. .Iwazaki M. . Delayed hemothorax superimposed on extrapleural hematoma after blunt chest injury: a case report. Tokai J Exp Clin Med. 2013;38:97-102 [PubMed]journal. [PubMed]
 
Hyacinthe A.C. .Broux C. .Francony G. .et al Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma. Chest. 2012;141:1177-1183 [PubMed]journal. [CrossRef] [PubMed]
 
Mathis G. .Blank W. . The chest wall.Mathis G.. Chest Sonography.  :- [PubMed]journal
 
Yu C.J. .Yang P.C. .Wu H.D. .Chang D.B. .Kuo S.H. .Luh K.T. . Ultrasound study in unilateral hemithorax opacification. Image comparison with computed tomography. Am Rev Respir Dis. 1993;147:430-434 [PubMed]journal. [CrossRef] [PubMed]
 
Wu R.G. .Yang P.C. .Kuo S.H. .Luh K.T. . “Fluid color” sign: a useful indicator for discrimination between pleural thickening and pleural effusion. J Ultrasound Med. 1995;14:767-769 [PubMed]journal. [PubMed]
 
Görg C. .Bert T. . Transcutaneous colour Doppler sonography of lung consolidations: review and pictorial essay. Part 1: pathophysiologic and colour Doppler sonographic basics of pulmonary vascularity. Ultraschall Med. 2004;25:221-226 [PubMed]journal. [CrossRef] [PubMed]
 
Görg C. .Bert T. . Transcutaneous colour Doppler sonography of lung consolidations: review and pictorial essay. Part 2: colour Doppler sonographic patterns of pulmonary consolidations. Ultraschall Med. 2004;25:285-291 [PubMed]journal. [CrossRef] [PubMed]
 
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