|| Curious Case
Fri, 26 Jul 1996 20:08:41 +0100
From: Karim Brohi [firstname.lastname@example.org]
Does anyone have a good (better)
explanation for this one...
Young man (drug user) arrives having
been stabbed left chest, anterior axillary line, 4th interspace.
Knife unknown. On admission, P 140 BP85/50 O2sat 85% Clinically
bilateral equal air entry, mediastinum, trachea not displaced.
CXR - Tension pneumothorax so needle
thoracostomy and then chest tube same interspace left side.
Second CXR - lung almost fully expanded.
Right chest field much whiter than previously.
Obs now P 105 BP 120/70 O2sat 98%
Patient intubated/ventilated for
CT chest with RSI (as too uncooperative) Spiral CT chest (within
about 25 minutes of arrival) with contrast small left pneumothorax.
Chest tube adequately placed. RIGHT chest half full of blood.
No mediastinal injury seen. No extravasation of contrast.
Patient stabilised haemodynamically
in CT. Chest drain insertd in intensive care. about 800 mls blood
drained over 1 hour then stopped. Patient did very well, went
back to the ward.
Any ideas where the right haemothorax
came from (there were no other stab wounds anywhere)? Best suggestion
we've had is that the knife passed anterior to the heart and took
out the left internal mammary vessels. If so this guy is the one
to get next week's lottery numbers from.
|| Date: Fri, 26 Jul 1996
From: Harvey Louzon [email@example.com]
It seems as if he improved immediately
after decompression of the left chest with stabilization of his
vital signs. Would this have been likely if a pre-existing injury
were present in the right chest? If an internal mammary artery
injury occured initially would you not expect to have seen evidence
of a right hemothorax on the original film? Have delayed hemothraces
been desrcibed after this type of injury? It seems as if he developed
the right hemothorax very soon after the left lung was expanded.
I would ask whether a left subclavian catheter was placed or not.
There are case reports of contralateral hemothoraces from perforation
of the SVC (1,2) or pericarium (3) via the left subclavian route.
Lock RL; Triplett HB; Rose G
Contralateral tension pneumo/hemothorax resulting from left subclavian
vein cannulation under general anesthesia.
Nurse Anesth, 2: 2, 1991 Jun, 89-92
A patient had a subclavian vein
catheter placed under general endotracheal anesthesia with positive
pressure ventilation. During placement, the superior vena cava,
pleura, and pulmonary tissue were punctured, resulting in a tension
pneumo/hemothorax, the detection of which was complicated by its
slow onset and unusual location. The lesion required an emergent
thoracotomy for repair.
Bardosi L; Mostafa SM; Wilkes RG; Wenstone R
Contralateral haemothorax: a late complication of subclavian vein
Br J Anaesth, 60: 4, 1988 Mar, 461-3
Contralateral haemothorax developed
as a late complication of subclavian vein cannulation following
gradual erosion of the wall of the superior vena cava by the tip
of the catheter. The use of a relatively rigid catheter and a
left-sided approach may have contributed to this rare, but potentially
Krauss D; Schmidt GA
Cardiac tamponade and contralateral
hemothorax after subclavian vein catheterization.
Chest, 99: 2, 1991 Feb, 517-8
A patient developed life-threatening
cardiac tamponade and contralateral hemothorax after insertion
of a subclavian catheter in the operating room. Contrast was infused
through the catheter, demonstrating its malposition in the pericardial
space. Contrast infusion was valuable in evaluating this complication
of central line placement.
|| Date: Sat, 27 Jul 1996 19:01:52
From: Dr. Karim Brohi [firstname.lastname@example.org]
There were no atempts at central line
placement. The patient was supine for the chest XRays, and brought
in fairly rapidly by ambulance. So a developing whiteness of the
right chest indicated the haemothorax. In retrospect, the initial
film was lighter on the right, but the presence of tension pneumothorax
on the left could have explained why that side was darker.
|| Date: Sat, 27 Jul 1996
From: Bradley K. Mosiman [email@example.com]
One of the residents did a retrospective
review of IMA injuries at our hospital last year. Several of these
injuries did not show up initially, but rather after moving to
SICU. In fact one delayed rupture occured two weeks later, after
dismissal. The patient had a knife injury to the chest, observed,
did well, dismissed. Two weeks later the patient was involved
in a bar fight and was brought in, full arrest, unable to resuscitate.
Autopsy showed delayed rupture from the previously undetected
|| Date: Sun, 28 Jul 1996
From: Chris Stonell [firstname.lastname@example.org]
I have had a similar experience
with a patient 2 years ago (hence don't recall vials accurately)
in Durban, SA.
Single stab (? knife used) to left
chest posteriorly, +-4 ICS, +- median scapula line, marked respiratory
distress on arrival, haemodynamically stable. IV access obtained
- can't remember volumes of fluids infused. Initial CXR: left
Pneumothorax - drained with underwater IC drain, marked improvement
in patients respiratory status. Pt admitted and observed.
Overnight increasing respiratory
distress developed. Repeat CXR showed large right sided haemo-pneumothorax.
Second ICD inserted and chest drained. Patient improved dramatically.
No persistant drainage from the chest after initial drainage (again
- can't recall volume). (No central lines in place.) No sings
of mediastinal injury on either film.
In view of the injury and findings
the patient was sent to the cardio-thoracic unit where they could
not indentify any site of bleeding into the right chest,or any
mediastinal injury (at least without opening the chest and finding
patient followed up by the Cardio-thoracic's
whith no further problems developing (as far as I'm aware)
|| Date: Tue, 30 Jul 1996
From: Dave Adams [email@example.com]
Had a similar case here last month.
Young male stabbed in Lt subclavian region. Details of incident
very unclear but patient alive at time of ambulance retrieval.
Only 5 minutes from hospital so they "scooped and ran".
Patient arrested coming through
the doors of resusc. dept. The Surg. registrar was on the scene
& did immediate Lt emergency bay thoracotomy and commenced open
CPR. No blood in chest. Pt did not respond.
Autopsy showed 2,000ml blood in
Rt thorax. Knife had passed above the pleura on the Lt side, across
the superior mediastinum, and into Rt thorax taking out upper
lobe pulmonary vessels. Bad luck!