Presentation
Right chest wall stabbing. Hypotensive and tachycardic.
Patient Data
Large right pneumohemothorax. Minor mediastinal shift to the left.
The ETT and right ICC are well positioned. Near complete decompression of the right pneumothorax. Persistent right hemothorax causing a veiling density. No mediastinal shift.
ETT, right ICC, NGT and right femoral CVL appropriately positioned.
Penetrating injury with trajectory extending through between the anterolateral aspect of the right 6th intercostal space, extending through adjacent pleura, anterior right lower lobe, diaphragm and peritoneal cavity where there is a laceration in superior aspect of the right lobe of the liver, involving hepatic segments 8 and 7. The laceration extends through the liver further posteriorly, where there is an additional breach through the posterior aspect of the diaphragm, pleura and the posterior right lower lobe. Within the liver laceration active arterial contrast extravasation is pooling on the subsequent portal venous and delayed phases. The hyperdense hemorrhage pools within the right subphrenic space and appears to be decompressing through the diaphragmatic defect into the right pleural space, where there is an associated large volume right hemothorax.
Tubular traumatic pneumatocele within the right lower lobe with adjacent ground-glass opacification representing pulmonary hemorrhage. The pneumatocele appears contiguous with segmental right lower lobe bronchi likely representing a bronchial injury. Trace pneumothorax, with gas anterior to the right middle lobe.
Patchy consolidation and ground-glass changes within the left lower lobe and dependent regions of the left upper lobe likely represents aspiration.
Trace pneumoperitoneum adjacent to the right lobe of the liver. Subcutaneous emphysema, tracking along fascial planes secondary to the penetrating injury and ICC insertion.
The thoracic and abdominal aorta have a normal caliber with no evidence of a thoracic or abdominal aortic injury.
No central pulmonary embolism. No size-significant mediastinal, hilar or axillary lymphadenopathy.
No additional intra-abdominal injury. The major abdominopelvic viscera are normal. The portal vein and its major tributaries are patent.
No fracture identified. Bilateral gynecomastia.
Impression
Penetrating thoracoabdominal stab injury that breaches multiple anatomical spaces. The laceration extends in the anterolateral aspect of the right 6th intercostal space, through the anterior pleura, anterior right lower lobe, anterior diaphragm, right lobe of the liver, posterior diaphragm, posterior pleura and posterior right lower lobe.
Active contrast extravasation within the hepatic laceration likely arises from a segmental branch of the right hepatic artery, extending into the right subphrenic space and appears to be decompressing into the right pleural cavity where there is a large hemothorax.
The right ICC is in appropriate position within the large right hemothorax. Small volume right pneumothorax.
Tubular pneumatocele within the right lower lobe amd adjacent ground glass change concordant with pulmonary hemorrhage. The pneumatocele appears contiguous with adjacent right lower lobe segmental bronchi likely representing bronchial injury.
Evidence of left lung aspiration.
Small volume pneumoperitoneum.
Case Discussion
Trauma laparatomy was performed in which a 4 cm right diaphragm defect was repaired, floseal was applied to the liver laceration and the right hemothorax was washed out (and subsequently required a VATS) and the ICC replaced. The patient had an uneventful recovery.
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