Iatrogenic pulmonary hemorrhage related to chest drain in trauma patient

Case contributed by Andrew Dixon


Car accident.

Patient Data

Age: 75 years
Gender: Male

NGT is misplaced with tip in the right lower lobe. ETT appropriately positioned. Old ununited right clavicle midshaft fracture and old right sided rib fractures. Likely acute incompletely imaged right proximal humeral fracture. No hemothorax or pneumothorax. Cardiomediastinal contour and venous congestion are normal for the supine position of the patient. 

Since the trauma chest x-ray, bilateral intercostal catheters have been inserted and the nasogastric tube has been successfully placed within the stomach. The right chest drain enters the parenchyma of the right lower lobe and becomes kinked. At the site of kinking there is a large volume of active contrast extravasation due pulmonary vessel injury (vein or artery) with extensive surrounding pulmonary hemorrhage and traumatic pneumatocele. The pulmonary hemorrhage was not present on the trauma chest x-ray in keeping with iatrogenic injury related to the intra-pulmonary passage of the ICC. There is also active contrast extravasation around the right drain tube within the chest wall suggesting arterial injury at this site also.  The left intercostal catheter also appears to be partially intrapulmonary with small volume of related pulmonary hemorrhage without active contrast extravasation. Acute fractures of the right third to seventh ribs anteriorly and acute fracture of the right surgical neck of humerus. Multiple old right sided rib fractures and old right clavicle fracture. 

Case Discussion

Chest decompression with placement of a drain in the pleural space can be a life-saving procedure in trauma patients. The procedure is not without complication however. In this case both the left and right drain tubes penetrate the lung parenchyma with the right tube having caused a substantial pulmonary vascular injury with active contrast extravasation and rapid pulmonary hemorrhage. In addition, there is also arterial bleeding in the chest wall related to the right drain tube. 

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