History of Present Illness
A 58-year-old Caucasian man was taken to the emergency room (ER) after a motorcycle accident (collision with a car). The patient had thoracic and head trauma.
Past Medical History
The patient had been suffering from paroxysmal atrial fibrillation for about 8 years and was regularly taking anticoagulant therapy for stroke prevention. One year earlier, vitamin K antagonist (warfarin, dose adjusted for a target international normalized ratio [INR] of 2–3) was replaced with a direct oral anticoagulant (dabigatran 150 mg two times daily). The patient had been using a nocturnal continuous positive airway pressure (CPAP) device for 5 years for obstructive sleep apnea syndrome (OSAS).
Physical Examination and Early Clinical Findings
At the ER, the patient was found to be alert and had pain in his right hemithorax. The first measurement of oxygen saturation showed very low values (Sp O 2 78%) and the administration of oxygen 15 L/min via a face mask with reservoir (fraction of inspired oxygen [Fi O 2 ] approximately 90%) was needed to obtain Sp O 2 of 94% or greater. Breaths were frequent (around 40/min) and shallow. The patient had no signs of subcutaneous emphysema in the neck or chest. Breath sounds were reduced at the lower right pulmonary field.
Blood pressure was 105/70 mm Hg. Hemoglobin was 11.2 g/dL. Coagulation tests revealed an increase in prothrombin time (PT: 16 seconds; normal range 11.0–13.0 seconds), INR was 1.58 (normal values < 1.1), and activated partial thromboplastin time (aPTT) was 50 seconds (normal range 25–35 seconds). Leukocytes and inflammatory indices were just above the normal limits (white blood cell [WBC] count 11,900 cells/μL; C-reactive protein [CRP] 12 mg/L). The patient had an occipital scalp laceration, which was promptly closed with surgical staples.
The patient underwent total-body computed tomography (CT), which identified multiple bilateral rib fractures. On the right side, some ribs were broken in several parts, and a few bone fragments had reached the pleural cavity. Right pleural effusion suggestive of hemothorax (maximum thickness 27 mm) and thin right pneumothorax (maximum thickness 7 mm) were evident, as well as large hyperdensity in the right upper lobe, resulting from pulmonary contusion, and hyperdensity in the right lower lobe in contiguity with the pleural effusion, resulting from partial atelectasis ( Figs. 19.1 and 19.2 ). The patient also had a spinous process fracture of the T2 vertebra, and bilateral slightly displaced sacral ala fractures at the level of S1–S3, without spinal cord injury. The findings from brain and abdomen CT were unremarkable.
Clinical Course
Opioid analgesics were administered (intravenous morphine 0.1 mg/kg during ambulance transport, followed by intravenous fentanyl 100 μg). The patient underwent endotracheal intubation and received invasive mechanical ventilation and then was admitted to the intensive care unit (ICU).
Because the patient was deeply sedated and intubated, his wife gave the consent for thoracic drainage. Prothrombin complex concentrate (PCC) was administrated to obtain rapid replacement of coagulation factors. Under ultrasound guidance, the thoracic surgeon performed an exploratory puncture at the seventh right intercostal space along the middle axillary line. He used a syringe previously filled with anesthetic (lidocaine 20 mg/mL, 1 ampule of 10 mL corresponding to 200 mg). Dark blood came out of the pleural cavity. A subsequent small incision was made with the tip of the scalpel, and a small-bore pleural drain (12-French [Fr]) was placed. This was secured to the skin with a 2-0 silk suture and connected to an underwater seal drainage system. About 300 mL of dark blood was evacuated in a few minutes, and 200 mL of bloody fluid came out in the next 12 hours. Minor transient air leaks were observed as well. Chest radiography confirmed good drain positioning and showed reduction of pleural effusion.
Unfortunately, after a further 24 hours later, sudden worsening of the oxygen parameters was observed. The movements of the right hemithorax were extremely reduced, and breath sounds on this side were almost absent. Repeat chest CT revealed large right pneumothorax with slight contralateral displacement of the mediastinal structures ( Fig. 19.3 ).
Computyed tomography (CT) pneumothorax (See )
The thoracic surgeon then urgently placed a chest drain in the fourth right intercostal space, along the anterior axillary line ( Fig. 19.4 ). Because adequate time had passed from suspension of the anticoagulant and because the hemoglobin level was stable, a large-bore chest tube (28-Fr) was used. It was secured to the skin with a 0 silk suture and connected to a three-chamber drainage system ( Fig. 19.5 ). There was abundant air leakage, which persisted for several days, manifesting as continuous bubbling. The lower pleural drain was found to be blocked by clots and was therefore removed.
