The utility of serial chest X-rays for detection of delayed pneumothorax, haemothorax or haemopneumothorax following penetrating thoracic injury.

INTRODUCTION: Penetrating thoracic injuries are a common presentation in Emergency Departments in South Africa with pneumothorax, haemothorax and haemopneumothorax (PTX/HTX/HPTX) a cause of morbidity and mortality. Serial chest X-rays (CXRs) are used to assess patients with penetrating thoracic injury without PTX/HTX/HPTX on initial CXR in order to increase sensitivity and thus detection of PTX/HTX/HPTX. This study aimed to assess the utility of serial CXRs to detect a delayed presentation of PTX/HTX/HPTX following penetrating thoracic injury. METHODS: This retrospective observational study analysed data from Helen Joseph Hospital Emergency Department, Johannesburg, South Africa for patients presenting with penetrating thoracic injury over a 2-year period for whom the initial CXR was negative for a PTX/HTX/HPTX to determine the utility of serial CXRs for detection of a delayed presentation of PTX/HTX/HPTX. RESULTS: 118 patients, the majority of which had penetrating trauma secondary to a stab wound, were included in the study. Eight (7%) had a PTX/HTX/HPTX detected on subsequent investigation. Three (3%) patients with normal initial CXRs and three (3%) patients with abnormal initial CXRs had a PTX/HPX/HPTX detected on serial CXRs. Two (2%) delayed presentations of PTX/HTX/HPTX were noted on computerised tomography (CT) scan only. Six patients had an intercostal drain (ICD) inserted and were admitted; 2 patients (those with PTX/HTX/HPTX noted on CT only) were managed conservatively. Three patients (3%) had an ICD inserted to manage a delayed presentation of PTX/HTX/HPTX with a normal initial CXR. DISCUSSION: Only 3% of patients with normal initial CXRs required intervention. CONCLUSIONS: It is recommended that patients for whom the presentation CXR shows an abnormality undergo serial CXRs. Given the low incidence of PTX/HTX/HPTX in patients with a normal presentation CXR, along with the resource implications of serial CXRs, it may be prudent to discharge patients with thorough counselling and advice to return for review if warranted.

Emergency video-assisted thoracoscopic surgery for haemopneumothorax and diaphragm repair after stabbing, performed through pre-existing wounds.

Video of video-assisted thoracoscopic surgery (VATS) on a 16-year old who had been stabbed. The knife penetrated the diaphragm, lung and intercostal pedicle causing a haemopneumothorax. A chest drain was inserted by the trauma team. VATS was performed entirely through the stab and chest drain pre-existing wounds without extension.

A Case of Missed Giant Bullae Emphysema Diagnosed as Pneumothorax

We report a case of a giant bullous emphysema misdiagnosed as a pneumothorax. A 18-year-old chronic smoker presented with right sided chest pain and dyspnoea. Initial respiratory rate was 35 /min, blood pressure was 136/90 mmHg, heart rate 80/min and SpO2 was 98% on room air. Clinical examination revealed reduced right air entry and left trachea deviation. Chest X-ray helped to arrive at a diagnosis of pneumothorax. Needle aspiration was then performed followed by a chest tube thoracostomy because of no improvement. Massive amount of blood was drained and patient deteriorated further. CT thorax revealed a right haemopneumothorax with multiple bullaes. Patient was rushed to OT for emergency thoracotomy for stapling of the ruptured bullae. Giant bullous emphysema can mimic pneumothorax and physician must be vigilant if draining a suspected pneumothorax.

Etiology and management of spontaneous haemothorax.

Spontaneous haemothorax (SH) is a subcategory of haemothorax that involves the accumulation of blood within the pleural space in the abscence of trauma or other causes. The clinical presentation is variable and includes a rapid progression of symptoms of chest pain and dyspnea that can be life threatening when hemodynamic instability and hypovolemic shock occurs. Despite haemothorax, SH is much less common with data limited to case reports and case series. A literature review has been performed to identify and summarise all potentials causes leading to this clinical entity.