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A case of a traumatic chyle leak following an acute thoracic spine injury: successful resolution with strict dietary manipulation
Andrea M Pakula, Wendy Phillips, Ruby A Skinner
World Journal of Emergency Surgery , 2011, DOI: 10.1186/1749-7922-6-10
Abstract: A 51 year old male presented as a tier one trauma code due to an automobile versus bicycle collision. His examination and radiographic work-up revealed fractures and a subluxation at the third and fourth thoracic spine levels resulting in paraplegia. He also sustained bilateral hemothoraces secondary to multiple rib fractures. Drainage of the left hemothorax led to the diagnosis of a traumatic chylothorax. The thoracic spine fractures were addressed with surgical stabilization and the chylothorax was successfully treated with drainage and dietary manipulation.This unusual and complex blunt thoracic duct injury required a multidisciplinary approach. Although the spine injury required surgical fixation, successful resolution of the chyle leak was achieved without surgical intervention.The majority of reported cases of chylothorax are due to malignancy (50%) specifically non-Hodgkin's lymphoma. Chylothorax due to traumatic thoracic injuries including iatrogenic post surgical injuries comprise approximately twenty-five percent of cases. Other iatrogenic complications primarily related to central access catheters make up the remaining twenty-five percent [2,3]. This disease process, if not properly recognized and treated can lead to profound respiratory, nutritional and immunological dysfunction resulting in significant patient morbidity and mortality. The available treatment modalities include conservative management with drainage and strict dietary regulation or more invasive approaches namely thoracic duct ligation [4,5].The patient is a 51 year old male who was struck by an automobile at 35 miles per hour while riding a bicycle. There was loss of consciousness in the field and he arrived to our level II trauma center in full spine precautions, as a tier one trauma code. His primary survey was intact and his initial vital signs were; BP 115/80, HR 84, RR 30, O2 saturation 89% on room air which improved to 98% on a non-rebreather mask at 100%. Pertinent findings on sec
Ultrasonographyin diagnosis of thoracic diseases
Stevi? Ru?a,Jakovi? Radoslav,Ma?ulovi? Dragan,Nagorni-Obradovi? Ljudmila
Medicinski Pregled , 2010, DOI: 10.2298/mpns1002086s
Abstract: Introduction. Chest sonography was used until recently mainly for diagnosis of pleural diseases. High resolution ultrasound machines enable ultrasound application not only in pleural diseases detection, but in diagnosing peripheral lung and mediastinal lesions. Ultrasonography can define the origin and structure of the lesion of thoracic wall, pleural and peripheral lung lesions and mediastinal lesions. Pleural lesions. Ultrasonography is very useful in diagnosing pleural effusion and distinguishing pleural fluid and pleural thickening. This method can also differentiate transudate from exudates and tumor mass from pleural thickening. Lung lesions. Ultrasonography can reveal the cause of white hemithorax differentiating pleural effusion from large tumor mass or atelectasis. Peripheral pulmonary lesions, extending into visceral pleura can be visualized by ultrasonography and differentiation solid tumor from inflammation is possible. Mediastinal lesions. Computerized tomography and magnetic resonance are methods of choice in diagnosing mediastinal diseases. Ultrasonography is useful in distinguishing normal thymus from tumor mass and for ultras onographyguided biopsy. Conclusion. Ultrasonography is a very useful second line method in diagnosis of chest disease. The advantages of this method include bed side availability, absence of radiation, and guided aspiration of fluid-filled areas and solid tumors.
Role of Thoracic Sonographic Scan in Diagnosis of Pneumothorax  [PDF]
Kawa A. Mahmood, Aram Baram, Fahmi H. Kakamad, Kosar K. Ahmed
International Journal of Medical Physics,Clinical Engineering and Radiation Oncology (IJMPCERO) , 2015, DOI: 10.4236/ijmpcero.2015.43030
Abstract: Background: Pneumothorax is a common problem seen in patients with acute and chronic medical and traumatic conditions with wide range of clinical presentations ranging from subtle decrease in breath sounds to cardiopulmonary arrest caused by tension pneumothorax. Pneumothorax is traditionally diagnosed by chest radiography, ultrasound is fairly a new modality of diagnosis. Ultrasound is a rapid noninvasive bedside test that may reduce mortality from this pathology by early detection. There are certain sonographic criteria that can exclude or confirm pneumothorax; this work has been performed to analyze these criteria. Patients and Methods: The study was done in Sulaimani teaching hospital and Sulaimani emergency hospital from June 1st to 10th August 2013. We performed thoracic ultrasound on fifty three diagnosed cases of pneumothorax (by chest X-ray &/or thoracic computed tomography). The age of the patients ranged between (10 - 82 years), mean age (38 years), 35 males and 18 females. Lung sliding sign, lung point sign and A line signs were recorded and analyzed. Results: The sensitivity, specificity, positive predictive value and negative predictive values of absent lung sliding sign were: 100%, 94%, 94% and 100% respectively, for lung point sign were: 70%, 100%, 100% and 68% respectively, for A line sign were: 91%, 71%, 73% and 91% respectively, for absent lung sliding and lung point sign together were 70%, 100%, 100% & 68.9% respectively. Conclusion: We confirmed the conclusion of other studies which stated that presence of lung sliding excludes pneumothorax and identification of lung point in a case with absent lung sliding is diagnostic of pneumothorax.
Stab Injury of the Thoracic Aorta: Computed Tomography Findings  [PDF]
Seyma Yildiz,Huseyin Toprak,Asli Serter,Ercan Kocako?
Case Reports in Radiology , 2013, DOI: 10.1155/2013/397514
Abstract: Stab injury of the thoracic aorta is a rare condition with high mortality rate. Patients must be evaluated carefully, and the diagnosis usually should be confirmed by radiological modalities. In this case, we report a 37-year-old man presented with a penetrating stab injury to the upper back and the thoracic aorta, and the diagnostic role of computed tomography is discussed. 1. Introduction Thoracic traumas take the third place after head and extremity traumas in patients with trauma who presented to emergency department. Thoracic traumas cause the 20–25% of deaths due to trauma in the first four decades of life [1]. Thoracic traumas are caused by blunt and penetrating injuries. Stab injuries of the thoracic aorta are rare. Because the thorax contains the heart, lungs, and great vessels, any thoracic injury of this space is associated with a high mortality rate. In thoracic traumas, accurate diagnosis and appropriate surgical approach form the basis of reducing the morbidity and mortality in such injuries. In this case we report a patient who was admitted to our emergency department due to stab injuries in the upper back region, and diagnostic tools of computed tomography (CT) are discussed. 2. Case Report A 37-year-old unresponsive man with penetrating injuries was admitted to our emergency department. On his physical examination, pulse and blood pressure could not be retrieved. Glasgow coma scale was determined as 3. There were 3?cm long bleeding laceration at the infrascapular region and midline 4?cm long bleeding laceration at the lumbar region. He was accepted as a respiratory and cardiac arrest; he was resuscitated and he responded to resuscitation. During evaluation of thorax, minimal pneumothorax was revealed, a chest tube was inserted, and 4 units of erythrocyte suspension were given to the patient. In order to evaluate the intrathoracic lesions, a contrast-enhanced CT was performed. Thorax CT examination revealed bilateral high density fluid collections at pleural space which were considered as hemothorax, left-sided pneumothorax, and an intraparenchymal hematoma in left lower laterobasal segment of the lung (Figure 1). Soft-tissue density hematoma that was surrounding trachea posteriorly and aorta circumferentially was seen in posterior mediastinum (Figure 2). From this area, adjacent to descending thoracic aorta, active contrast material leak was seen, and therefore this was considered as aortic rupture and contrast material extravasation due to acute aortic rupture (Figure 3). The patient underwent an operation by thoracic and
Treatment of a Prolonged Air Leak with Radiotherapy: A Case Report  [PDF]
Erdo?an ?etinkaya,M. Akif ?zgül,?ule Gül,Ertan ?am,Yakup Büyükpolat
Case Reports in Pulmonology , 2012, DOI: 10.1155/2012/158371
Abstract: Pneumothorax is defined as air in the pleural space. Depending on the severity of the pneumothorax, treatment consists of oxygen therapy, simple aspiration, tube thoracostomy, and pleurodesis. Prolonged air leakage is observed in 25% of the patients who have undergone surgical procedures, such as thoracotomy, pleurectomy, and video-assisted thoracoscopy. The patient presented here is the third reported case successfully treated with radiotherapy. Ventilation scintigraphy was used to localise the air leak, and localised radiotherapy was performed at the targeted location. After radiotherapy, the air leak ceased and at the 3-month followup, the pneumothorax had not recurred. Radiotherapy can be a treatment modality for patients with prolonged air leak, who are not candidates for surgery. 1. Introduction Prolonged air leakage is observed in 25% of the patients who have undergone surgical procedures. In patients who are not candidates for surgical treatment, alternative methods are used to treat the prolonged air leak. We present a case who has air leakage for 1 month and successfully treated with radiotherapy. 2. Case A 77-year-old male patient was admitted to the intensive care for respiratory failure and a pneumothorax was identified; tube thoracostomy was performed. The patient’s general condition improved and he was extubated and discharged after ending the tube thoracostomy. The patient was readmitted 15 days later due to shortness of breath, and right recurrent pneumothorax was identified. The tube thoracostomy was repeated. After performing negative aspiration and talc pleurodesis twice, the patient’s drainage ended on day 14. The patient was readmitted 15 days later due to shortness of breath. In his history, he had smoked cigarettes for 60 pack/years and had been treated for chronic obstructive pulmonary disease (COPD) for 10 years. A posteroanterior (PA) chest X-ray showed bilaterally increased emphysematous ventilation in the lung parenchyma and a total pneumothorax in the right lung (Figure 1). On thoracic-computed tomography (CT), bullous areas at the apexes of both lungs and a right pneumothorax were observed (Figure 2). Figure 1: Chest radiography: a total pneumothorax in the right lung. Figure 2: Thorax CT: bullous areas at the apexes of both lungs and a right pneumothorax. Surgery was considered, but was contraindicated by the patient’s advanced age and comorbidities (cardiac failure and severe COPD). Based on a published report, radiotherapy treatment was attempted. Ventilation scintigraphy showed findings consistent with the refractory
Intrapleural instillation of autologous blood for persistent air leak in spontaneous pneumothorax- is it as effective as it is safe?
Dimos Karangelis, Georgios I Tagarakis, Marios Daskalopoulos, Georgios Skoumis, Nicholaos Desimonas, Vasileios Saleptsis, Theocharis Koufakis, Athanasios Drakos, Dimitrios Papadopoulos, Nikolaos B Tsilimingas
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-61
Abstract: A number of 15 patients (10 male and 5 female) were included in this prospective study between March 2005 and December 2009. The duration of the air leak exceeded 7 days in all patients. The application of blood pleurodesis was used as the last preoperative conservative method of treatment in 12 patients. One patient refused surgery and two were ineligible for operation due to their comorbidities. A blood sample of 50 ml was obtained from the patient's femoral vein and immediately introduced into the chest tube.A success rate of 27% was observed having the air leak sealed in 4 patients in less than 24 hours.Despite our disappointingly poor outcome, the authors believe that the procedure's safety, convenience and low cost establish it as a worth trying method of conservative treatment for patients with the aforementioned pathology for whom no other alternative than surgery would be a choice.Persistent air leak is frequently encountered in thoracic surgery especially after pulmonary surgery or pneumothorax. It prolongs patient's hospital stay and is considered to be a difficult problem regarding its management [1,2]. Pleurodesis is an excellent method used to treat air leak and it is feasible by means of surgery, autologous blood and several intra-pleural chemical agents such as talc powder, tetracycline, doxycycline, bleomycine ect. Regardless of the method, surgical or conservative, the goal of pleurodesis is to provoke adhesions between the parietal and the visceral pleura and thus minimize the space between the two layers. In the case of surgery this is achieved by mechanical irritation of the parietal pleura while sclerotic agents induce dense adhesions chemically. Autologous blood irritates the pleural surfaces and is considered to act by formatting a patch of clotted blood (fibrin), which can potentially adhere to the lung parenchyma that produces the leak. Nevertheless, according to some authors blood can also act like a sclerotic agent causing a few adhesions
Theoretical Calculation of Resonant Frequencies of the Human Alveolar Wall and Its Implications in Ultrasound Induced Lung Hemorrhage  [PDF]
D. John Jabaraj,Mohamad Suhaimi Jaafar
International Journal of Bioscience, Biochemistry and Bioinformatics , 2013, DOI: 10.7763/ijbbb.2013.v3.153
Abstract: The human alveolar wall was modeled here asmembranes and its resonant frequency was determined in orderto analyze the mechanism of alveolar resonance of theultrasound induced lung hemorrhage. The resonant frequencyof the membrane models of the human alveolar wall wasdetermined to be within the range of the frequency of diagnosticultrasound used in the thoracic and abdominal regions; whichis > 2.5 MHz. Thus, the alveolar resonance is proved to occurduring the diagnostic ultrasound imaging of humans. Howeverthe possibility of alveolar wall damage at resonance was notanalyzed here. Nevertheless according to the resonant frequencyequations derived here, the resonance of the alveolar wall bydiagnostic ultrasound waves can be eliminated from occurringwhen total lung capacity is ~ 20% (at maximal expiration)
Establishment of A Clinical Prediction Model of Prolonged Air Leak ?after Anatomic Lung Resection  [PDF]
Xianning WU, Shibin XU, Li KE, Jun FAN, Jun WANG, Mingran XIE, Xianliang JIANG, Meiqing XU
- , 2017, DOI: : 0.3779/j.issn.1009-3419.2017.12.06
Abstract: Background and objective Prolonged air leak (PAL) after anatomic lung resection is a common and challenging complication in thoracic surgery. No available clinical prediction model of PAL has been established in China. The aim of this study was to construct a model to identify patients at increased risk of PAL by using preoperative factors exclusively. Methods We retrospectively reviewed clinical data and PAL occurrence of patients after anatomic lung resection, in department of thoracic surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, from January 2016 to October 2016. 359 patients were in group A, clinical data including age, body mass index (BMI), gender, smoking history, surgical methods, pulmonary function index, pleural adhesion, pathologic diagnosis, side and site of resected lung were analyzed. By using univariate and multivariate analysis, we found the independent predictors of PAL after anatomic lung resection and subsequently established a clinical prediction model. Then, another 112 patients (group B), who underwent anatomic lung resection in different time by different team, were chosen to verify the accuracy of the prediction model. Receiver-operating characteristic (ROC) curve was constructed using the prediction model. Results Multivariate Logistic regression analysis was used to identify six clinical characteristics [BMI, gender, smoking history, forced expiratory volume in one second to forced vital capacity ratio (FEV1%), pleural adhesion, site of resection] as independent predictors of PAL after anatomic lung resection. The area under the ROC curve for our model was 0.886 (95%CI: 0.835-0.937). The best predictive P value was 0.299 with sensitivity of 78.5% and specificity of 93.2%. Conclusion Our prediction model could accurately identify occurrence risk of PAL in patients after anatomic lung resection, which might allow for more effective use of intraoperative prophylactic strategies.
Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers
Vicki E Noble, Lionel Lamhaut, Roberta Capp, Nichole Bosson, Andrew Liteplo, Jean-Sebastian Marx, Pierre Carli
BMC Medical Education , 2009, DOI: 10.1186/1472-6920-9-3
Abstract: 27 Paris Service D'Aide Médicale Urgente (SAMU) physicians at the H?pital Necker with varying levels of US experience were given two twenty-five image recognition pre-tests; the first test had examples of both normal and pneumothorax lung US and the second had examples of both normal and pulmonary edema lung US. All 27 physicians then underwent the same didactic training modules. A post-test was administered upon completing the training module and results were recorded.Pre and post-test scores were compared for both the pneumothorax and the pulmonary edema modules. For the pneumothorax module, mean test scores increased from 10.3 +/- 4.1 before the training to 20.1 +/- 3.5 after (p < 0.0001), out of 25 possible points. The standard deviation decreased as well, indicating a collective improvement. For the pulmonary edema module, mean test scores increased from 14.1 +/- 5.2 before the training to 20.9 +/- 2.4 after (p < 0.0001), out of 25 possible points. The standard deviation decreased again by more than half, indicating a collective improvement.This brief training module resulted in significant improvement of image recognition skills for physicians both with and without previous ultrasound experience. Given that rapid diagnosis of these conditions in the pre-hospital system can change therapy, especially in systems where physicians can integrate this information into treatment decisions, the further diffusion of this technology would seem to be beneficial and deserves further study.The diagnostic tools available to pre-hospital providers when faced with a dyspneic patient are limited. To date, diagnosis has largely relied on physical exam findings such as jugular venous distention, auscultation findings using a stethoscope or infared sensors of pulse-oximetry monitoring hemoglobin oxygenation. These findings are often unreliable (lack both sensitivity and specificity) and are even more difficult to identify in noisy or chaotic environments [1-3]. In addition, many
Co-occurrence of outlet impingement syndrome of the shoulder and restricted range of motion in the thoracic spine - a prospective study with ultrasound-based motion analysis
Christina Theisen, Ad van Wagensveld, Nina Timmesfeld, Turgay Efe, Thomas J Heyse, Susanne Fuchs-Winkelmann, Markus D Schofer
BMC Musculoskeletal Disorders , 2010, DOI: 10.1186/1471-2474-11-135
Abstract: Two sex- and age-matched groups (2 × n = 39) underwent a clinical and an ultrasound topometric examination. The postures examined were sitting up straight, sitting in maximal flexion and sitting in maximal extension. The disabilities of the arm, shoulder and hand (DASH) score (obtained by means of a self-assessment questionnaire) and the Constant score were calculated. Lengthening and shortening of the dorsal projections of the spine in functional positions was measured by tape with Ott's sign.On examination of the thoracic kyphosis in the erect seated posture there were no significant differences between the two groups (p = 0.66). With ultrasound topometric measurement it was possible to show a significantly restricted segmental mobility of the thoracic spine in the study group compared with the control group (p = 0.01). An in-depth look at the mobility of the subsegments T1-4, T5-8 and T9-12 revealed that differences between the groups in the mobility in the lower two sections of the thoracic spine were significant (T5-8: p = 0.03; T9-12: p = 0.02). The study group had an average Constant score of 35.1 points and the control group, 85.5 (p < 0.001). On the DASH score the patient group reached 34.2 points and the control group, 1.4 (p < 0.001). The results of Ott's sign differed significantly between the two collectives (p = 0.0018), but showed a weak correlation with the ultrasound topometric measurements (study group flexion/extension: r = 0.36/0.43, control group flexion/extension: r = 0.29/0.26).The mobility of the thoracic spine should receive more attention in the diagnosis and therapy of patients with shoulder outlet impingement syndrome.Impingement syndrome of the shoulder is a term used to describe a number of functional and structural restrictions. It was first described by the American surgeon Charles Neer [1,2] to mean an anatomic narrowing between the head of the humerus and the acromion. In his articles he describes symptoms arising in the shoulder wh
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