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.

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.

(1)
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.

(2)
Bardosi L; Mostafa SM; Wilkes RG; Wenstone R
Contralateral haemothorax: a late complication of subclavian vein cannulation.
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 fatal complication.

(3)
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.

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.

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 IMA injury.

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 the clot).

patient followed up by the Cardio-thoracic's whith no further problems developing (as far as I'm aware)

No but......

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!