Presentation
Hypotension and an acute drop in hemoglobin after an earlier discharge the same day post-treatment for spontaneous pneumothorax.
Patient Data
- massive amount of inhomogeneous, high-density fluid (25-60HU) in the right pleural cavity, consistent with intrathoracic hemorrhage
- ipsilateral lung compression (collapse of the upper, lower, and middle lobe)
- displacement of the trachea, mediastinum and the heart to the left side
- compression of the right brachiocephalic vein and the superior vena cava (SVC) with abundant venous collaterals
- three punctate foci of contrast extravasation extending from the anterolateral 4th intercostal space (at the site of the previously inserted and drawn chest tube) into the right pleural cavity suggesting the bleeding source
- soft tissue swelling and chest wall emphysema caudolaterally
Additional Findings:
- central venous catheter via the left internal jugular vein (IJV) with tip straight (not ideal) in the distal part of the vessel
- status post segmental resection of the left upper lobe (superior division and lingula)
- status post gastrectomy and splenectomy
Follow-up AP supine chest x-ray after thoracoscopy and placement of two chest tubes into the right hemithorax.
Trachea and cardio-mediastinal contours are almost back to midline.
Almost normal lucency of the right hemithorax with some residual fluid visible in the interlobar fissure.
Signs of mild pulmonary congestion.
Case Discussion
Tension hemothorax is a rare but life-threatening disorder.
The patient had an immediate thoracoscopic evacuation of the hemothorax and exploration of the right thoracic cavity as well as placement of two large-bore chest tubes.
Video-assisted thoracoscopic surgery (VATS) did not reveal any intrathoracic bleeding source, with unremarkable visceral and parietal Pleura.
The bleeding source was suspected to be an extrathoracic vessel (venous varix or branch of the lateral thoracic artery) and related to the withdrawal of the chest drain earlier the same day.
So the CT did help in the diagnosis and localization of the bleeding site.
The patient had a full recovery.
Side note on the central venous catheter (CVC) tip position:
Hemothorax is also a recognized complication of central venous catheterization.
Even though central venous catheter tip position is a somewhat controversial issue, in this case, the tip of the internal jugular vein catheter is obviously pointing towards a vessel wall (junction of distal IVJ and left brachiocephalic vein) and therefore “not ideal”.
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