May the initial CT scan predict the occurrence of delayed hemothorax in blunt chest trauma patients?

Abstract

Purpose

To assess the impact of delayed hemothorax on outcomes in blunt chest trauma patients without life-threatening condition at admission and characterize the predictive value of predefined anatomical factors for delayed hemothorax.

Methods

In a single-centre retrospective study, every spontaneous breathing patient admitted for a blunt chest trauma without significant pleural effusion at ICU admission was included. A multivariable regression model was used to determine the covariate-adjusted odd of secondary respiratory complications in patients with delayed hemothorax ≥ 500 ml. The characteristics of rib fractures (number, location and displacement) were integrated into a logistic regression model to determine variables associated with delayed hemothorax in multivariate analysis.

Results

Over the study period, 109 patients were included and the rate of delayed hemothorax ≥ 500 ml was 36%. Patients with delayed hemothorax had higher rates of pulmonary infections (OR 4.8 [1.6–16.4]) but no statistical association between delayed hemothorax and secondary respiratory failure (OR 2.0 [0.4–9.4]). A posterior location and a displaced rib fracture were independent predictors of delayed hemothorax (OR 3.4 [1.3–8.6] and OR 2.3 [1.1–5.1], respectively). At least one displaced rib fracture was more specific of delayed hemothorax than the commonly used threshold of three or more rib fractures (81.3 vs. 51.5%).

Conclusion

Delayed hemothorax is a frequent complication associated with increased risk of pulmonary infection. The posterior location and the displacement of at least one rib fracture in the initial CT scan were independent risk factors for predicting the occurrence of delayed hemothorax.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. 1.

    Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012;43(1):8–17.

    Article  Google Scholar 

  2. 2.

    Plourde M, Émond M, Lavoie A, Guimont C, Le Sage N, Chauny J-M, et al. Cohort study on the prevalence and risk factors for delayed pulmonary complications in adults following minor blunt thoracic trauma. CJEM. 2014;16(2):136–43.

    Article  Google Scholar 

  3. 3.

    Misthos P, Kakaris S, Sepsas E, Athanassiadi K, Skottis I. A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. Eur J Cardio Thorac Surg Off J Eur Assoc Cardio Thorac Surg. 2004;25(5):859–64.

    CAS  Article  Google Scholar 

  4. 4.

    Émond M, Sirois M-J, Guimont C, Chauny J-M, Daoust R, Bergeron É, et al. Functional impact of a minor thoracic injury: an investigation of age, delayed hemothorax, and rib fracture effects. Ann Surg. 2015;262(6):1115–22.

    Article  Google Scholar 

  5. 5.

    Mangram AJ, Zhou N, Sohn J, Moeser P, Sucher JF, Hollingworth A, et al. Pleural effusion following rib fractures in the elderly: are we being aggressive enough? J Gerontol Geriatr Res. 2016;5:341. https://doi.org/10.4172/2167-7182.1000341.

    Article  Google Scholar 

  6. 6.

    Simon BJ, Chu Q, Emhoff TA, Fiallo VM, Lee KF. Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity. J Trauma. 1998;45(4):673–6.

    CAS  Article  Google Scholar 

  7. 7.

    Bouzat P, Raux M, David JS, Tazarourte K, Galinski M, Desmettre T, et al. Chest trauma: First 48 h management. Anaesth Crit Care Pain Med. 2017;36(2):135–45.

    Article  Google Scholar 

  8. 8.

    Blecher GE, Mitra B, Cameron PA, Fitzgerald M. Failed emergency department disposition to the ward of patients with thoracic injury. Injury. 2008;39(5):586–91.

    Article  Google Scholar 

  9. 9.

    Mommsen P, Zeckey C, Andruszkow H, Weidemann J, Frömke C, Puljic P, et al. Comparison of different thoracic trauma scoring systems in regards to prediction of post-traumatic complications and outcome in blunt chest trauma. J Surg Res. 2012;176(1):239–47.

    Article  Google Scholar 

  10. 10.

    Yap D, Ng M, Chaudhury M, Mbakada N. Longest delayed hemothorax reported after blunt chest injury. Am J Emerg Med. 2018;36(1):171.e1–.e3.

    Article  Google Scholar 

  11. 11.

    Chien C-Y, Chen Y-H, Han S-T, Blaney GN, Huang T-S, Chen K-F. The number of displaced rib fractures is more predictive for complications in chest trauma patients. Scand J Trauma Resusc Emerg Med. 2017;25(1):19.

    Article  Google Scholar 

  12. 12.

    Carrier FM, Turgeon AF, Nicole PC, Trépanier CA, Fergusson DA, Thauvette D, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth J Can Anesth. 2009;56(3):230–42.

    Article  Google Scholar 

  13. 13.

    Miyamoto T, Sasaki T, Kubo T, Matsuo H, Miyatake K. Non-invasive determination of the quantity of pleural effusion and evaluation of the beneficial effect of pleuracentesis in patients with acute exacerbation of chronic congestive heart failure. J Cardiol. 1997;30(4):205–9.

    CAS  PubMed  Google Scholar 

  14. 14.

    Talmor M, Hydo L, Gershenwald JG, Barie PS. Beneficial effects of chest tube drainage of pleural effusion in acute respiratory failure refractory to positive end-expiratory pressure ventilation. Surgery. 1998;123(2):137–43.

    CAS  Article  Google Scholar 

  15. 15.

    Mowery NT, Gunter OL, Collier BR, Diaz JJ, Haut E, Hildreth A, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011;70(2):510–8.

    Article  Google Scholar 

  16. 16.

    Livingston DH, Shogan B, John P, Lavery RF. CT diagnosis of Rib fractures and the prediction of acute respiratory failure. J Trauma. 2008;64(4):905–11.

    Article  Google Scholar 

  17. 17.

    Roch A, Bojan M, Michelet P, Romain F, Bregeon F, Papazian L, et al. Usefulness of ultrasonography in predicting pleural effusions %3e 500 mL in patients receiving mechanical ventilation. Chest. 2005;127(1):224–32.

    Article  Google Scholar 

  18. 18.

    Eibenberger KL, Dock WI, Ammann ME, Dorffner R, Hörmann MF, Grabenwöger F. Quantification of pleural effusions: sonography versus radiography. Radiology. 1994;191(3):681–4.

    CAS  Article  Google Scholar 

  19. 19.

    Michelet P, Couret D, Brégeon F, Perrin G, D’Journo X-B, Pequignot V, et al. Early onset pneumonia in severe chest trauma: a risk factor analysis. J Trauma. 2010;68(2):395–400.

    Article  Google Scholar 

  20. 20.

    Boersma WG, Stigt JA, Smit HJM. Treatment of haemothorax. Respir Med. 2010;104(11):1583–7.

    Article  Google Scholar 

  21. 21.

    Heniford BT, Carrillo EH, Spain DA, Sosa JL, Fulton RL, Richardson JD. The role of thoracoscopy in the management of retained thoracic collections after trauma. Ann Thorac Surg. 1997;63(4):940–3.

    CAS  Article  Google Scholar 

  22. 22.

    Carrie C, Stecken L, Cayrol E, Cottenceau V, Petit L, Revel P, et al. Bundle of care for blunt chest trauma patients improves analgesia but increases rates of intensive care unit admission: a retrospective case-control study. Anaesth Crit Care Pain Med. 2018;37(3):211–5.

    Article  Google Scholar 

  23. 23.

    Unsworth A, Curtis K, Asha SE. Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery. Scand J Trauma Resusc Emerg Med. 2015;2015:8.

    Google Scholar 

  24. 24.

    Todd SR, McNally MM, Holcomb JB, Kozar RA, Kao LS, Gonzalez EA, et al. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg. 2006;192(6):806–11.

    Article  Google Scholar 

  25. 25.

    Dubinsky I, Low A. Non-life-threatening blunt chest trauma: Appropriate investigation and treatment. Am J Emerg Med. 1997;15(3):240–3.

    CAS  Article  Google Scholar 

  26. 26.

    Flores-Funes D, Lluna-Llorens AD, Jiménez-Ballester MÁ, Valero-Navarro G, Carrillo-Alcaráz A, Campillo-Soto Á, et al. Is the number of rib fractures a risk factor for delayed complications? A case–control study. Eur J Trauma Emerg Surg. 2018;2018:1–6.

    Google Scholar 

  27. 27.

    Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138(4):717–23 (discussion 723-725).

    Article  Google Scholar 

  28. 28.

    Jones KM, Reed RL, Luchette FA. The ribs or not the ribs: which influences mortality? Am J Surg. 2011;202(5):598–604.

    Article  Google Scholar 

  29. 29.

    Söderlund T, Ikonen A, Pyhältö T, Handolin L. Factors associated with in-hospital outcomes in 594 consecutive patients suffering from severe blunt chest trauma. Scand J Surg. 2015;104(2):115–20.

    Article  Google Scholar 

  30. 30.

    Whitson BA, McGonigal MD, Anderson CP, Dries DJ. Increasing numbers of rib fractures do not worsen outcome: an analysis of the national trauma data bank. Am Surg. 2013;79(2):140–50.

    Article  Google Scholar 

  31. 31.

    Bugaev N, Breeze JL, Alhazmi M, Anbari HS, Arabian SS, Rabinovici R. Displacement patterns of blunt rib fractures and their relationship to thoracic coinjuries: minimal displacements count. Am Surg. 2016;82(3):199–206.

    Article  Google Scholar 

  32. 32.

    Bugaev N, Breeze JL, Alhazmi M, Anbari HS, Arabian SS, Holewinski S, et al. Magnitude of rib fracture displacement predicts opioid requirements. J Trauma Acute Care Surg. 2016;81(4):699–704.

    Article  Google Scholar 

  33. 33.

    Carver TW, Milia DJ, Somberg C, Brasel K, Paul J. Vital capacity helps predict pulmonary complications after rib fractures. J Trauma Acute Care Surg. 2015;79(3):413–6.

    Article  Google Scholar 

  34. 34.

    Paydar S, Ghahramani Z, Ghoddusi Johari H, Khezri S, Ziaeian B, Ghayyoumi MA, et al. Tube thoracostomy (chest tube) removal in traumatic patients: what do we know? What Can We Do? Bull Emerg Trauma. 2015;3(2):37–40.

    PubMed  PubMed Central  Google Scholar 

Download references

Funding

The study received non-financial support.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Geoffrey Gonzalez.

Ethics declarations

Conflict of interest

All the authors have no competing interest.

Ethical statement

The work described has not been published before. This observational study was approved by our institutional Ethics Committee.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gonzalez, G., Robert, C., Petit, L. et al. May the initial CT scan predict the occurrence of delayed hemothorax in blunt chest trauma patients?. Eur J Trauma Emerg Surg 47, 71–78 (2021). https://doi.org/10.1007/s00068-020-01391-4

Download citation

Keywords

  • Rib fracture
  • Hemothorax
  • Displacement
  • Blunt chest trauma
  • Intensive care