Delayed Hemothorax and Pericardial Tamponade Secondary to Stab Wounds to the Internal Mammary Artery.pdf

8/10/2019 Delayed Hemothorax and Pericardial Tamponade Secondary to Stab Wounds to the Internal Mammary Artery.pdf

1/5

Case Study

Delayed Hemothorax and PericardialTamponade Secondary to Stab Wounds

to the Internal Mammary ArteryFausto Y. Vinces1

274 European Journal of Trauma 2005 No. 3 Urban&Vogel

European Journal of Trauma

Abstract

Background: Massive delayed hemothorax as a conse-quence of stab wounds to the internal mammary arteryhas been reported in only one study in the western liter-ature.

Case Study:A review of patients who sustained injuriesto the parasternal region with internal mammary ar-tery injuries is discussed. Three patients with injuries tothis structure that developed delayed a hemothoraxwere identified. One of the patients had a combinationof a delayed hemothorax and pericardial tamponade.All three patients were treated with emergency antero-lateral thoracotomies.

Conclusion: Internal mammary artery injuries had ahigh risk for the development of a delayed hemotho-rax. Patients with parasternal injuries should be ad-

mitted to a telemetry unit, where thoracostomy tubeoutputs and vital signs can be monitored continu-ously. The addition of sonography to identify bloodin the pericardial sac and a lateral chest X-ray view torule out an extrapleural hematoma are useful andshould be considered in the management of thesepatients.

Key Words

Internal mammary artery (IMA) Parasternal region(PS) Hemothorax (HT) Thoracostomy tube (TT)

Eur J Trauma 2005;31:2747

DOI 10.1007/s00068-005-1007-2

Introduction

Internal mammary artery injuries are usually secondary

to penetrating trauma to the precordial region. These

injuries are usually reported with other intrathoracic

vessel injuries. In the majority of patients who sustain

penetrating chest trauma, surgical intervention is per-

formed immediately after admission because of hemo-

dynamic instability or increased bloody output from a

thoracostomy tube. Delayed massive bleeding has been

described and is associated with a delayed hemothorax

that presents a few hours after placement of the thora-

costomy tube. A review of our trauma registry demon-

strated three patients who sustained stab wounds to the

parasternal area with internal mammary artery injuries

that developed a delayed hemothorax and in one case a

pericardial tamponade. These patients underwent im-

mediate exploratory thoracotomies with excellent re-sults.

Case Study

Patient 1

A 21-year-old male sustained multiple stab wounds to

his right chest. His vital signs included a heart rate of 93

beats per minute (bpm), blood pressure of 138/73

mmHg, respirations of 20, and oxygen saturation of

98%. The patient had three stab wounds located in the

following areas: right second and fifth intercostal space

at the midclavicular line level with an open pneumotho-

rax and one to the fifth intercostal space 2 cm from thesternum. A 36-F right chest tube was placed to relieve

1 Department of Surgery, Saint Barnabas Hospital, Bronx, NY, USA.

Received: June 9, 2004; revision accepted: November 26, 2004.


2/5

Vinces FY. Delayed Hemothorax Secondary to IMA Injuries

275European Journal of Trauma 2005 No. 3 Urban&Vogel

his pneumothorax, and 300 cm3of blood drainage was

obtained after its insertion. Focused abdominal sono-

gram for trauma (FAST) was negative for pericardial

fluid. Postinsertion chest X-ray demonstrated the lung

expanded and without evidence of hemothorax. The pa-tient was admitted to the intensive care unit, and 3 h

later the drainage of the chest tube started increasing to

175 cm3/h for the next 3 h with two episodes where the

systolic blood pressure decreased to 88 mmHg. Repeat

FAST was consistent with a pericardial effusion. The

patient was taken to the operating room for an emer-

gency thoracotomy that demonstrated a complete tran-

section of the right internal mammary artery with ap-

proximately 450 cm3of blood in the chest and 300 cm3of

blood in the pericardial sac causing a tamponade that

was relieved with a pericardiotomy. The right internal

mammary artery was ligated, and he was discharged on

postoperative day 7.

Patient 2

A 25-year-old male sustained a single stab wound to the

left parasternal region approximately 3 cm lateral from

the level of insertion of the fourth rib in the sternum.

His vital signs in the trauma bay were a heart rate of 102

bpm, blood pressure of 118/66 mmHg, respiratory rate

of 18, and a Glasgow Coma Score of 15. The patient un-

derwent the Advanced Trauma Life Support protocol

and a FAST exam that was negative for pericardial flu-id. A chest X-ray demonstrated a left pneumothorax,

and a 36-F left chest tube was placed with immediate

relief from his pneumothorax. However, approximately

250 cm3of blood drainage was obtained after the inser-

tion. The repeat chest X-ray demonstrated a fully ex-

panded lung. In the next 3 h in the emergency depart-

ment the patient had one episode where his systolic

blood pressure decreased to 72 mmHg but responded to

1-l bolus of crystalloids. His chest tube drainage had in-

creased to 600 cm3for the last 3 h. It was decided to take

the patient to the operating room for a left anterolateral

thoracotomy that demonstrated 600 cm3of blood in theleft chest cavity with a complete transection of the left

anterior mammary artery and active bleeding into the

left thoracic cavity. The artery was ligated, and he was

discharged on postoperative day 5.

Patient 3

A 19-year-old male sustained two stab wounds to his right

parasternal region at the level of the third and fourth ribs.

On his arrival to the trauma bay his vital signs were a

heart rate of 100 bpm, blood pressure of 132/68 mmHg,

and respiratory rate of 20. The patient underwent the

Advanced Trauma Life Support protocol, FAST exam

and a chest X-ray that were negative for tamponade but

demonstrated a right pneumothorax. A 36-F thoracosto-my tube was placed with expansion of the lung and 200

cm3of bloody drainage. The patient was admitted to the

telemetry unit where he had two episodes of hypotension

(systolic blood pressure of 82 mmHg). In addition, there

was an increased output from his thoracostomy tube to

approximately 750 cm3in 4 h. Due to these findings the

patient was taken to the operating room for a right an-

terolateral thoracotomy that demonstrated an injury to

the right internal mammary artery with 500 cm3of blood

on the right thoracic cavity. The artery was ligated, and

he was discharged on postoperative day 8.

Patients and Methods

A retrospective review of all stab wounds to the chest was

performed at St. Barnabas Hospital, a regional level I

trauma center in an urban setting in New York City,

USA. The trauma registry was used to identify patients

with this type of injury from June 2000 to May 2003. Their

records were reviewed, and the following data were re-

trieved: time of injury and surgical intervention, wound

location, chest tube insertion and output, chest X-ray film

reports, operative reports, structures injured, hospital

course, mortality and morbidity. Because of the anatomiclocation of the internal mammary artery, stab wounds to

the parasternal region were identified. This region was

described as being below the clavicles, between the mid-

clavicular lines, and above the costal margins.

Results

94 patients with stab wounds to the chest were identi-

fied. 29 of these patients had wounds that were paraster-

nal in location. Two of these patients were noted to have

internal mammary artery injuries with delayed hemo-

thoraces and one with a combined presentation of a de-

layed hemothorax and a pericardial tamponade. De-layed hemothorax occurred in all three patients within

8, 3 and 4 h, respectively, after placement of the thora-

costomy tube. Thoracostomy tubes were placed in all

patients with an initial output between 200 and 300 cm3

of blood. None of the three patients had evidence of a

residual hemothorax after placement of the thoracos-

tomy tube. In addition, there was not change in vital

signs or thoracostomy tube outputs during the first hour

of admission. However, upon admission to the teleme-


3/5


276 European Journal of Trauma 2005 No. 3 Urban&Vogel

try unit, three patients had consistently episodes of hy-

potension that partially responded to crystalloid bolus-

es. The only remarkable finding on chest X-ray was a

right lower lobe contusion on patient 1.

Discussion

The internal mammary artery arises from the subclavian

artery directly and courses down the chest wall anterior

to the pleura and endothoracic fascia (Figure 1). The

artery distance varies from the lateral sternal margin

and usually terminates at the sixth intercostal space as

the musculophrenic and superior epigastric arteries.The average diameter of the vessel is 2 mm, and com-

plete transection is the most common type of injury [1].

A completely transected vessel can potentially retract

and achieve hemostasis as a result of arterial spasm and

hypotension. However, this hemostasis can be disrupted

with aggressive resuscitation causing a delayed bleeding

that had been seen in three of our patients. Flow rates in

this blood vessel average 150 ml/m which can result in

massive hemothorax that can develop a few hours after

the injury [1].

Penetrating injuries to the chest are common and

usually require the placement of a thoracostomy tube torelieve either a pneumothorax or hemothorax. Series

describing penetrating chest trauma had been published

in the literature, but most of them have not specifically

focused on injuries to the internal mammary artery and

its relationship to delayed hemothorax and in some cas-

es delayed pericardial tamponade [2]. Demetriades et

al. identified internal mammary artery injuries, but

there was not a delayed massive hemothorax that re-

quired surgical intervention [3].

The parasternal area was described as a potentially

dangerous zone by Siemens et al., and they recommend-

ed routine surgical exploration of this region [4]. How-

ever, most of their patients sustained gunshot and not

stab wounds. Ritter & Chang reported two mortalitiesout of five patients, and both cases were associated with

a delayed hemothorax [1]. Their findings are consistent

with ours in that three of their patients did not have ini-

tial evidence of hemothorax but later developed signifi-

cant bleeding that required emergent intervention.

Our report confirms that stab wounds to the para-

sternal area should be treated with a high level of suspi-

cion even in hemodynamically stable patients. Internal

mammary artery injuries should be suspected, and if

there is a chest tube in place in these patients, drainage

should be monitored hourly. Our small series is unique

because all these patients were admitted to a telemetrybed where their vital signs were closely monitored.

Therefore, the periods of hemodynamically instability

were recorded and acted upon immediately. Figure 2

demonstrates the algorithm used at our institution to

manage precordial stab wounds. The use of the FAST

exam to rule out pericardial fluid is an extremely impor-

tant part of the initial evaluation of these patients. A

positive result will require the patient to go to the oper-

ating room for exploration. A negative result will re-

Figure 1. Anatomic cross section of the internal mammary vessels andsurrounding structures, 119 79 mm (300 300 DPI).

FAST positive

Operating room

Admit to telemetry unitRecord output every 1 h,vital signs every 30 min

Admit to surgical floorRepeat CXR in 6 h,vital signs every 4 h

Hypotension < 90 mmHgRefractory to fluid boluses withtube output > 200 cm3blood/h 23 h

Operating room Tube removal when output< 100 cm3/24 h

Discharge home after24 h if second CXRnegative

Precordial stab wounds

FAST negative

Thoracostomy tube required

No

No

Yes

Yes

Figure 2. Management of precordial stab wounds.


4/5


277European Journal of Trauma 2005 No. 3 Urban&Vogel

quire the patient to be admitted for a 24-h observation

period with a repeat two-view chest X-ray in 6 h. The

patient could be safely discharged after this period, if

the work-up is negative. However, if the patient has a

negative FAST but requires a tube thoracostomy, he/

she will be admitted to the telemetry unit where the vital

signs and thoracostomy outputs will be monitored. The

presence of hypotension (defined as a systolic bloodpressure < 90 mmHg), which is not responsive to crys-

talloid boluses, is an indicator that the patient may re-

quire immediate surgical intervention. This factor alone

or combined with increased output from the thoracos-

tomy tube (200 cm3of blood for 2 or 3 h) will indicate

the presence of a delayed hemothorax that will require

the patient to go to the operating room.

The exact etiology for the presence of a delayed he-

mothorax is not completely elucidated [5]. We had tried

to outline and describe three stages that explain the for-

mation of a delayed hemothorax. The first stage is the

transection of the vessel with a small laceration of thepleura or pericardium with the creation of an extrapleu-

ral hematoma [6]. Figure 3 demonstrates the anatomic

landmarks and formation of the hematoma. This extra-

pleural hematoma can be seen as a pulmonary contu-

sion on the initial chest X-ray. The second stage is the

communication of this hematoma with the pleural cavi-

ty secondary to its increase in size and pressure. There is

evidence that small lacerations of the pleura occur dur-

ing this type of injury and that blood can leak into the

pleural cavity and pericardial sac creating a massive he-

mothorax or pericardial tamponade. In the third stage,

there will be an increase in output from the thoracosto-

my tube with hemodynamic instability. This clinical pre-

sentation will require an urgent thoracotomy to controland ligate the bleeding vessel. Finally, in selected and

hemodynamically stable patients, embolization therapy

had been used as an alternative to thoracotomy in chest

wall trauma [7, 8].

Conclusion

As a result of these findings, our protocol includes a

FAST exam to examine the pericardium for blood. In

hemodynamically stable patients, a two-view chest

X-ray film or a computed tomography of the chest is

obtained to rule out an extrapleural hematoma. Finally,

admission to a monitored bed is recommended in order

to maintain an adequate vigilance over vital signs and

thoracostomy tube outputs.

References1. Ritter DC, Chang FC. Delayed hemothorax resulting from stab

wound to the internal mammary artery. J Trauma 1995;39:5869.2. Mandal AK, Oparah SS. Unusually low mortality of penetrating

wounds of the chest. J Thorac Cardiovasc Surg 1989;97:11925.3. Demetriades D, Rabinowitz B, Markides N. Indications for thora-

cotomy in stab injuries of the chest: a prospective study of 543patients. Br J Surg 1986;73:88890.

4. Siemens R, Polk HC, Gray LA, et al. Indications for thoracotomy fol-

lowing penetrating thoracic injury. J Trauma 1977;17:493 500.5. Mohlala ML, Vanker EA, Ballaram RS. Internal mammary arteryhaematoma. S Afr J Surg 1989;27:1368.

6. Curley SA, Demarest GB, Hauswald M. Pericardial tamponade andhemothorax after penetrating injury to the internal mammaryartery. J Trauma 1986;27:9578.

7. Carrillo EH, Heniford BT, Senler SO, et al. Embolization therapy asan alternative to thoracotomy in vascular injuries of the chestwall. Am Surg 1998;64:11428.

8. Whigham CJ, Fisher RG, Goodman CJ, et al. Traumatic injury of theinternal mammary artery: embolization versus surgical and non-operative management. Emerg Radiol 2002;9:2017.

Address for Correspondence

Fausto Y. Vinces, DOSection of Trauma and Critical CareDepartment of SurgerySaint Barnabas Hospital2nd Floor, Third Ave. and 183rd St.Bronx, NY 10457USAPhone (+1/718) 960-6127, Fax -6132e-mail: [email protected]

Figure 3. Formation ofan extrapleural hema-toma with hemothorax,75 119 mm (300 300DPI).


5/5

Reproducedwithpermissionof thecopyrightowner. Further reproductionprohibitedwithoutpermission.

Documents

Delayed Hemothorax and Pericardial Tamponade Secondary to Stab Wounds to the Internal Mammary Artery.pdf