62 year old PMH COPD AF Metallic AVR on warfarin Left sided chest pain increased breathlessness Observations normal isolated episode of pyrexia CXR moderate left sided pleural effusion ID: 1047137
Download Presentation The PPT/PDF document "SpR 1 Matt Dickson Day 1" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. SpR 1Matt Dickson
2. Day 162 year old PMH: COPD, AF, Metallic AVR (on warfarin)Left sided chest pain, increased breathlessnessObservations normal – isolated episode of pyrexiaCXR – moderate left sided pleural effusionCT – no evidence of malignancyINR 7.5 – no Hx of trauma (warfarin held, 1mg oral Vit K)CRP mildly elevated (60)Abx started∆∆ Simple parapneumonic effusion vs malignancy vs haemothorax
3. Day 2CRP >400USS revealed unilocular, large effusionMore likely complicated parapneumonic effusion/empyemaBeriplex and IV vitamin K given12 Fr Seldinger inserted – no bleeding/immediate complicationsSlightly turbid, serous fluid drainingpH 6.8 Antibiotics continuedTherapeutic enoxaparin commenced 1mg/kg BD
4. Day 3, 4 and 5Drained 2.5 litresOozing blood from drain site, one dose enoxaparin withheld on Day 3 but continued thereafterStopped draining day 5, clot noticed in tubeDrain removed evening of day 5
5. Day 6 UnwellCRP 500Hypotensive, reduced GCS, clammyType 2 RF, sats 80% on 15l/minNo bleeding around drain site, no haematomaNo significant drop in Hb Day 5
6. Day 6Initial thoughts – likely septic shockResponded to IVT, inotropes, BiPAPPlanned for ITUPEA arrest, down time of 9 minutes (sustained rib fractures)Spurious Hb results
7. Repeat USS
8. Day 6 Hb had dropped from 120 to 60Hypovolaemic shock secondary to haemothoraxStabilised in ITULiaised with haematology and cardiothoracics
9. HaemothoraxCollection of blood within pleural cavityEffusion should contain at least 50% of the haematocrit of peripheral bloodCauses: Mostly sharp/blunt traumaIatrogenicSpontaneous (rupture of pleural adhesions, anticoagulation, cancer)
10. PathogenesisSome degree of defibrination through motion of organs within thoraxIncomplete clottingPleural enzymes can break down clotIf large collection, clot inevitableAdhere to parietal and visceral pleuraMembrane thickens with timeLung becomes trappedFibrothoraxEmpyema
11. ManagementWhat we can do:Chest drain (>28Fr)Prophylactic antibiotics (for at least first 24 hours)Imaging (CT/USS)Intrapleural fibrinolytic therapy (within first 7 – 10 days advisable) e.g. alteplase
12. ManagementIndications for surgery:EarlyIf drainage >1.5L /24 hours or >200ml/hour, refer to cardiothoracicsIf stable – VATSIf unstable – thoracotomyLateIf after initial management, haemothorax persistsSurgery best in first 48-72 hoursThoracotomy indicated if complex
13.
14. What you might see through USSHaematocrit sign
15. What you might see through USS
16. What you might see through USSPlankton sign
17. Complicating factors in this caseMetallic heart valve, need for anticoagulationWould alternative anticoagulant changed his outcome?Parapneumonic effusion/empyema prior to haemothoraxUnable to drain haemothorax earlyToo unstable to transfer to CTxIssue of ongoing anticoagulation for valve
18. References1. Ali HA, Lippmann M, Mundathaje U, Khaleeq G. Spontaneous hemothorax: a comprehensive review. Chest 2008;134:1056e65.2. Boersma WG, Stigt JA, Smit HJM. Treatment of haemothorax. Respiratory Medicine 2010; 104: 1583-1587
19. Thank you