Complication to consider: delayed traumatic hemothorax in older adults

Abstract

BackgroundEmerging evidence suggests older adults may experience subtle hemothoraces that progress over several days. Delayed progression and delayed development of traumatic hemothorax (dHTX) have not been well characterized. We hypothesized dHTX would be infrequent but associated with factors that may aid prediction.MethodsWe retrospectively reviewed adults aged ≥50 years diagnosed with dHTX after rib fractures at two level 1 trauma centers (March 2018 to September 2019). dHTX was defined as HTX discovered ≥48 hours after admission chest CT showed either no or ‘minimal/trace’ HTX. Two blinded, board-certified radiologists reviewed inpatient chest imaging and classified injury patterns according to Chest Wall Injury Society (CWIS) taxonomy. Descriptive analysis was performed for demographic and hospitalization characteristics.ResultsWe identified 14 patients with pooled dHTX rate of 1.3%. After initial chest CT negative for concerning hemothoraces, the patients did not undergo follow-up imaging until new symptoms (shortness of breath, chest pain) developed: eight (57%) were not diagnosed until after discharge from initial hospitalization (mean (range): 9 (2–20) days after discharge). Aspirin and/or anticoagulants were involved in fewer than half of cases (43%). According to CWIS taxonomy, all patients had a series of posterolateral fractures with at least one offset or displaced fracture, and an average of six consecutive rib fractures. All patients underwent tube thoracostomy and six patients (42%)—all aged <65—underwent operative interventions.DiscussionPreliminary data suggest older adults with rib fractures may be at risk of experiencing delayed progression of trace hemothoraces or a delayed presentation of hemothoraces. Asymptomatic progression or readmission to other services/hospitals likely occurs and true dHTX rates are likely higher. Our preliminary findings suggest a possible anatomic explanation for severe chest wall injury patterns’ association with dHTX. Further characterization and capturing the true incidence of dHTX first requires wider recognition of this complication.

Unmasking the Unforeseen: A Case of Radiological Tension Empyema Mimicking a Traumatic Hemothorax

“…This, coupled with the absence of any recent chest infection and apyrexia at the time of presentation, led the clinicians to reach the diagnosis of a likely delayed traumatic hemothorax. Delayed development of trauma-related hemothorax is rare but has been reported in the literature [ 10 ].…”

Predictors of pleural complications in trauma patients undergoing tube thoracostomy: A prospective observational study

“…Menger et al, in 2012, identified the severity of chest injury classified by the AIS as the only independent factor related to post drainage complications 23 . There are studies that report a greater chance of late and after discharge rebleeding in approximately 1.4% of patients with chest injuries 24 , 25 .…”

DeepBackRib: Deep learning to understand factors associated with readmissions after rib fractures

“…The study cohort comprised index hospitalization encounters of nonelderly adults (aged 18-64 years) hospitalized with a principal diagnosis of traumatic injury and any diagnosis of multiple rib fractures (International Classification of Diseases, Tenth Revision [ICD-10], diagnostic code, S22.4). We excluded elderly adults based on our hypothesis that their readmission etiologies are more likely to be confounded by baseline health conditions or associated with disparate etiologies (e.g., delayed hemothoraces 11,12 ). To mitigate confounding the association with our outcome (all-cause 3-month readmissions), we included patients with isolated major thoracic injuries (Abbreviated Injury Scale ≥3 of chest and <3 of other body regions).…”

“…The study cohort comprised 20,260 patients with rib fractures, among whom 11% (n = 2,185) experienced 3-month readmissions. Compared with patients who did not experience 3-month readmissions, patients who experienced 3-month readmissions were older (mean [SD] age, 51 [11] years vs. 48 [12] years) and had a lower proportion discharged to home after index hospitalization (78% vs. 91%; Table 1). Supplementary Figure 1, http://links.lww.com/TA/C703, displays the study cohort flow diagram, and Supplementary Table 3, http://links.…”