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Grand Rounds Vol 7 pages 5457

Speciality: Thoracic Surgery


Article Type: Case Report
DOI: 10.1102/1470-5206.2007.0015
2007 e-MED Ltd

Conservative management of large


intrapulmonary haemorrhage following
penetrating chest trauma
D.J. Marsh, S. Mills and F.W. Cross
Royal London Hospital, London, E1 1BB, UK
Corresponding address: Sarah Mills, Royal London Hospital, London, E1 1BB, UK.
E-mail: sarahmills530@hotmail.com
Date accepted for publication 8 May 2007

Abstract
Penetrating chest wounds can hide a range of life threatening injuries and often require
emergency surgical management. It is important that the patient be assessed and managed
according to clinical need and response to medical intervention. This is a case of a patient with a
large intrapulmonary haematoma who was managed conservatively and made a good recovery
without need for surgery.

Keywords
Intrapulmonary haematoma; penetrating chest trauma; conservative.

Case report
We present the case of a 23-year-old man brought to our Accident and Emergency
Department with multiple stab wounds to the upper posterolateral thorax. On admission he
was tachycardic at 110 bpm but maintaining his blood pressure at 120/90 mmHg. Pulse oximetry
showed saturations of 99% on room air. Clinical examination of the thorax revealed reduced right
sided breath sounds and the chest was dull to percussion right midzone. Assessment continued
along advanced trauma life support (ATLS) guidelines and plain chest radiographs were taken
which showed a large pulmonary haematoma in the right midzone (Fig. 1). The patients
observations remained stable with no fall in blood pressure or oxygen saturation levels.
Repeat chest radiographs taken at intervals of 15 min showed a moderate increase in the size
of the haematoma and following these, a contrast enhanced computed tomography (CT) scan
of the thorax was performed.
The CT scan revealed a 9 cm intrapulmonary haematoma in the right midzone with a ground
glass appearance in the peripheries of the upper right lobe consistent with parenchymal
haemorrhage (Fig. 2). The arterial phase of the scan showed active extravasation of contrast within
the haematoma and there was evidence of chest wall surgical emphysema at the site of the stab
wounds.
The patient was admitted to the High Dependency Unit of our hospital for observation,
commenced on prophylactic antibiotics and a repeat chest radiograph taken 24 h post injury
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Conservative management of large intrapulmonary haemorrhage

55

Fig. 1.

Fig. 2.

showed no further increase in the size of the haematoma (Fig. 3). As the patients condition
continued to improve, he was discharged from hospital 48 h post admission. A repeat chest
radiograph was taken a week following the injury (Fig. 4).

Discussion
Penetrating injury to the thorax may result in serious morbidity and mortality[1,2]. Often patients
present in extremis following injury to thoracic viscera; however, when the patients clinical
condition remains stable, a conservative approach can be adopted. In the case presented here, the
haemorrhage into the lung parenchyma was self-limiting and had minimal effects on the patients
lung function.
If patients with penetrating chest wounds continue to haemorrhage, options for controlling the
bleeding include radiographic guided angioembolisation of the bleeding vessel via the bronchial
arterial tree. This requires a skilled radiologist as although the bronchial arteries most commonly
originate from the descending aorta between T5 and T6 vertebrae, aberrant anatomy has been
reported in 1535% of patients and paralysis following inadvertent embolisation of the spinal
arteries has been described[3]. If embolisation is not an option or haemorrhage continues after

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D.J. Marsh et al.

Fig. 3.

Fig. 4.

embolisation, then the patient requires urgent referral to a thoracic surgeon for thoracotomy
and direct ligation of the bleeding vessel.
A review of the literature found there to be little data available on managing traumatic
intrapulmonary haemorrhage conservatively presumably as most patients with such injuries
are unstable. A case series from Bulgaria[4] looked at 18 patients over 14 years with
intrapulmonary haematoma and of these, 15 were managed surgically and 3 conservatively.

Conservative management of large intrapulmonary haemorrhage

57

There was no difference in outcome between the two groups. Serial CT examinations may also be
used to monitor progress[5]. A review of thoracic injuries in World War 2 reports on a series of
89 cases of intrapulmonary haemorrhage or haematoma managed conservatively, and reports
that these lesions resolved spontaneously within 46 weeks. Furthermore, follow up radiographs
at 5 months showed no evidence of any long term sequelae of the haematoma[6].

Teaching point
This case illustrates that intrapulmonary haematomas may be managed non-operatively with good
outcomes. The point is also made that patient management should be dictated by clinical
condition and not by radiographic means alone.

References
1. Kulshrestha P, Munshi I, Wait R. Profile of chest trauma in a level I trauma centre. J Trauma
2004; 5757681.
2. Chen SC, Kauder DR, Schwab CWJ. Penetrating chest injury: who warrants aggressive
treatment? Formos Med Assoc 1998; 973679.
3. Kim YG, Yoon HK, Ko GY, Lim CM, Kim WD, Koh Y. Long-term effect of bronchial artery
embolization in Korean patients with haemoptysis. Respirology 2006; 1177681.
4. Obretenov E, Petrov D, Kalaidzhiev G, Plochev M. Surgical treatment of post traumatic
intrapulmonary haematomas. Khirurgiia (Sofia) 2002; 58247.
5. Melloni B. Vergnenegre A, Bonnaud F, et al. Post-traumatic pulmonary hematomas. Apropos
of 2 cases. Rev Mal Respir 1989; 626770.
6. Surgery in World War II.Thoracic SurgeryVol 2Medical Department, United States Army498.