.
CONCLUSIONS
Unlikely Indication for Chest Tube Placement in a Trauma Setting
Zilmarie Díaz Pacheco, MD, José M. Acevedo Rodríguez, MD, Jaime A. Aponte-Ortiz, MD MS, Cristina Joy-Perez MD
Department of Emergency Medicine, University of Puerto Rico, San Juan, Puerto Rico
Department of General Surgery, University of Puerto Rico, San Juan, Puerto Rico
EXHIBITS
REFERENCES
Introduction
Common chest tube placement indications in a trauma setting include hemothorax and pneumothorax. Empyema is also an indication for chest tube placement, most commonly in a patient with bacterial pneumonia and parapneumonic effusions. We present a case of a patient who developed a tension empyema during a Trauma Surgery admission and its acute management.
Case Presentation
59 yo M with PMHx of untreated HIV and substance use disorder who presented initially to the ED for multiple body trauma after a pedestrian accident. Patient suffered a splenic laceration which was managed with splenic artery embolization. Around two weeks after discharge, patient returned to ED due to a splenic abscess. The morning after evaluation, patient developed respiratory distress and hemodynamic instability. Chest XR performed shows tension empyema, which accumulated over the course of approximately 26 hours.
Conclusions
CASE PRESENTATION
ABSTRACT
Case of a 59 year old male with PMHx of untreated HIV and substance use disorder who presented initially to the emergency department at Centro Medico de Puerto Rico after multiple body trauma in a pedestrian accident on 6/28/23. Patient suffered Grade IV splenic laceration with moderate hemoperitoneum, and left sided 9-10th rib fractures. Patient underwent aortogram, splenic arteriogram and splenic artery AV fistula and pseudoaneurysm embolization on 6/29/23 and was eventually discharged home on 7/6/23.
On 8/12/23, the patient returned to a different ED for fever and abdominal pain. Patient underwent an abdominopelvic CT with IV contrast which demonstrated extensive splenic necrosis with a foci of gas within the fluid collection concerning for a splenic abscess. Patient was transferred to Centro Medico de Puerto Rico for further management of splenic abscess.
Patient arrived at Centro Medico de Puerto Rico on 8/14/2023. Initial evaluation with vital signs and physical exam findings as below. Chest XR within normal limits on admission, at 2:55AM (Exhibit A). Interventional radiology was consulted for management of splenic abscess.
�V/S: P: 94, BP 124/84 (97), RR: 21, T: 36.0, O2 sat: 97% RA
General: Awake, alert, and oriented x3 and in no acute distress
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation bilaterally, regular rate and rhythm
Abdomen: Soft, nondistended, moderate LUQ tenderness on palpation
Extremities: Full range of motion, pulses 2+ in all extremities, no edema
Neurologic: GCS 15/15
� On the morning of 8/15/2023 at 6:19M,, the patient developed acute shortness of breath. Vitals signs at the moment listed below. Septic shock was suspected for which IV fluids, labs, antibiotics, and chest XR (Exhibit B) were ordered .
�V/S: P 125, BP 80/52 (62), RR: 30, T 36.9C, O2 sat: 95% RA
� Upon revision of chest XR, patient was taken to Stabilization Unit for tension hydrothorax management. A left sided thoracostomy tube was placed. Tube initially drained close to 1500mL of brown, purulent fluid (Exhibit C). Patient improved hemodynamically after the procedure. Follow up chest XR in Exhibit D. Fluid samples were taken for culture and analysis. Blood cultures were obtained and patient was started on empiric antibiotics. Final pleural fluid cultures show methicillin susceptible S. Aureus and fluid analysis consistent with exudative effusion. Patient taken to OR for partial splenectomy, drainage of perisplenic abscess, Bogota bag placement and subsequent re-entry laparotomy, peritoneal lavage, and placement of intraperitoneal drainage
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BACKGROUND
DISCUSSION
Author Emails:
Zilmarie Díaz Pacheco: zilmarie.diaz@upr.edu
José M. Acevedo Rodriguez: jose.acevedo4@upr.edu
Jaime A. Aponte-Ortiz: jose.aponte@upr.edu
Cristina Joy-Pérez joyperezcm@gmail.com
A
B
CONTACT INFO:
C
D
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Immunocompromised patients are susceptible to opportunistic and complicated infections. Empyemas are an example of a complication from pneumonia that can be seen in these patients. Although pneumothorax is far more likely to cause tension pathophysiology, our differential should include empyema as a cause of hemodynamic instability in this particular patient population. � � The patient described above accumulated an empyema large enough to cause hemodynamic instability in around 26 hours. The questions stands whether this is due to transdiaphragmatic spread, diaphragmatic inflammation or an intrathoracic primary infection. �� Regardless of etiology, tension empyema is managed in the same way as tension pneumothorax, with decompression via tube thoracostomy. Flash pulmonary edema is a complication of chest tube drainage of large volumes of fluid or air from the thoracic cavity if done rapidly. It is essential to be on the lookout for worsening respiratory difficulty in these patients if >1.5L are drained. �
Empyemas can lead to hemodynamic instability if exudative effusions accumulate rapidly or in large volumes, This should be identified and managed in a timely manner. In the case of our patient, the questions still stands of whether the infection occurred from transdiaphragmatic spread or as a complication of his chronic HIV. �
Patients discharged after multiple body trauma should be educated on symptomatology that should warrant them to return to the ED for reevaluation, as complications from initial trauma and management may arise.
Empyema occurs as a complication of a pneumonic process in which there is accumulation of a purulent effusion which may compromise pulmonary expansion and therefore, vital capacity. Tension pathophysiology has been extensively described in cases of pneumothorax, in which pulmonary collapse and compression lead to hemodynamic compromise warranting emergent decompression. Tension empyema is a rare pathology described scantly in literature and we present a case in the setting of trauma of a patient with a history of longstanding, untreated HIV infection. � � Pleural effusions have been reported in cases of HIV patients, however, they are predominantly due to pneumonia, opportunistic infections, or malignancy. Subphrenic abscesses have been described as etiology of pleural effusions based on diaphragmatic inflammation which increases capillary patency and leads to translocation of fluid towards the pleural cavity.