The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Letters to the Editor , SMALL BUT MIGHTY: UNUSUAL CAUSE OF MASSIVE MEDIASTINAL HEMATOMA
over the pericardium. Subsequent contrast-enhanced thoracic computed tomography (CT) scan revealed a massive substernal hematoma (10 5 cm at the widest portion) and a 5-mm foreign body with metallic density (Figure 1, A and B). Also, interruption of the flow of contrast material in the midportion of the left internal mammary artery (LIMA) was detected. Emergency surgery with partial median sternotomy was performed. The hematoma, with fresh blood and blood clots, was seen in the anterior mediastinum. Remarkably, a metallic foreign body with sharp edges was found over the hematoma (Figure 2). During the surgery, 1500 mL of blood and blood clots, including metallic foreign body, were evacuated from the mediastinum. There was no blood in the pleural cavities. After careful inspection, transection in the mid-portion of the LIMA was seen when the clot over this area was dislodged (Figure 3). Both ends of the transected LIMA were ligated. There were no other sources of bleeding. Hemostasis was successfully accomplished. A small pericardiotomy was performed, and the heart and proximal great vessels were examined. There was no evidence of active bleeding from or damage to any structure within the pericardium. The patient was hemodynamically stable after the surgery. After an uneventful postoperative course, he was discharged on the 5th day after surgery. Isolated injury of the internal mammary artery (IMA) has been rarely described in penetrating anterior thoracic trauma, and most of those injuries are
, To the Editor: Sharma et al. reported in 2010 on “Stab Wound of the Neck with Contralateral Hemo-Pneumothorax,” and we have another interesting case to report, of massive mediastinal hematoma caused by tiny penetrating material, as opposed to stab wound (1). A 62-year-old, otherwise healthy man presented to the Emergency Department (ED) with trauma to the left side of the chest that occurred while splitting firewood with an axe. On examination, blood pressure was 120/90 mm Hg, pulse was 68 beats/ min, the respiratory rate was 22 breaths/min, and the oxygen saturation was 98% in room air. There was a 3-mm entrance wound with minimal bleeding found on the left midclavicular line over the nipple. There was no swelling or ecchymosis on the chest wall. The patient was mildly lethargic. Breath sounds were clear bilaterally but heart sounds were diminished. Bedside focused assessment with sonography for trauma (FAST) examination revealed no pneumothorax, no hemothorax, no intraperitoneal fluid, and no pericardial effusion. Chest radiograph and electrocardiogram revealed no detectable abnormalities. Seeing that the patient was obtunded, bedside transthoracic echocardiography (TTE) was performed. The heart was found to be posteriorly displaced due to a hematoma
Figure 1. Massive substernal hematoma (A, white arrows) and metallic foreign body (B, white arrow) in contrast-enhanced computed tomography scan (A, axial section; B, sagittal reconstruction).
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Letters to the Editor
Figure 2. Metallic foreign body thought to have detached from either the axe or nails on the firewood. It is approximately 7 mm in length and has sharp edges.
caused by high-energy penetration, as from a gunshot or stabbing (2). Isolated IMA injuries have delayed consequences like mediastinal hematoma rather than causing acute hemorrhagic shock, because even a completely divided vessel can potentially retract and achieve hemostasis as a result of arterial spasm and hypotension (3). Because the anterior mediastinum is a shallow space, an expanding hematoma caused by IMA injury may result in serious complications (4). The mediastinal hematoma may serve as a threat to hemodynamic stability, not only as a source of blood loss, but also as a potential source of compression of vascular structures such as the heart, and pulmonary arteries (5). A prompt, thorough search and accurate diagnosis of a hematoma is crucial, but early recognition of isolated IMA injury is difficult. Chest radiography, FAST, and TTE have low sensitivity and specificity. Thus, for stable patients, CT scan can be the proper diagnostic tool. If contrast-enhanced CT scan is utilized, an entire series of the IMA can be imaged to elucidate any injury. In contrast to most of the reported cases of isolated IMA injury after penetrating injury, our case is unique with respect to cause of injury. A very minute foreign body transected the LIMA and caused a massive anterior mediastinal hematoma. In conclusion, regardless of the size of causative material in penetrating traumas, all chest wall traumas should be evaluated equally. TTE and CT scan should be the diagnostic modalities of choice.
Figure 3. Active hemorrhage caused by total transection was seen in the midportion of the left internal mammary artery prior to bifurcation.
Safak Alpat, MD, PHD Onur Saydam, MD Hasan Aydin, MD Riza Dogan, MD Department of Cardiovascular Surgery Hacettepe University School of Medicine Ankara, Turkey http://dx.doi.org/10.1016/j.jemermed.2013.08.143
REFERENCES 1. Sharma OP, Blaney J, Oswanski MF, Assi Z, DiSalle R, Latocki V. Stab wound of the neck with contralateral hemo-pneumothorax. J Emerg Med 2010;39:e135–8. 2. Mandal AK, Oparah SS. Unusually low mortality of penetrating wounds of the chest. Twelve years’ experience. J Thorac Cardiovasc Surg 1989;97:119–25. 3. Ritter DC, Chang FC. Delayed hemothorax resulting from stab wounds to the internal mammary artery. J Trauma 1995;39:586–9. 4. Irgau I, Fulda GJ, Hailstone D, et al. Internal mammary artery injury, anterior mediastinal hematoma, and cardiac compromise after blunt chest trauma. J Trauma 1995;39:1018–21. 5. Braatz T, Mirvis SE, Killeen K, et al. CT diagnosis of internal mammary artery injury caused by blunt trauma. Clin Radiol 2001; 56:120–3.
Letters to the Editor , SMALL BUT MIGHTY: UNUSUAL CAUSE OF MASSIVE MEDIASTINAL HEMATOMA
over the pericardium. Subsequent contrast-enhanced thoracic computed tomography (CT) scan revealed a massive substernal hematoma (10 5 cm at the widest portion) and a 5-mm foreign body with metallic density (Figure 1, A and B). Also, interruption of the flow of contrast material in the midportion of the left internal mammary artery (LIMA) was detected. Emergency surgery with partial median sternotomy was performed. The hematoma, with fresh blood and blood clots, was seen in the anterior mediastinum. Remarkably, a metallic foreign body with sharp edges was found over the hematoma (Figure 2). During the surgery, 1500 mL of blood and blood clots, including metallic foreign body, were evacuated from the mediastinum. There was no blood in the pleural cavities. After careful inspection, transection in the mid-portion of the LIMA was seen when the clot over this area was dislodged (Figure 3). Both ends of the transected LIMA were ligated. There were no other sources of bleeding. Hemostasis was successfully accomplished. A small pericardiotomy was performed, and the heart and proximal great vessels were examined. There was no evidence of active bleeding from or damage to any structure within the pericardium. The patient was hemodynamically stable after the surgery. After an uneventful postoperative course, he was discharged on the 5th day after surgery. Isolated injury of the internal mammary artery (IMA) has been rarely described in penetrating anterior thoracic trauma, and most of those injuries are
, To the Editor: Sharma et al. reported in 2010 on “Stab Wound of the Neck with Contralateral Hemo-Pneumothorax,” and we have another interesting case to report, of massive mediastinal hematoma caused by tiny penetrating material, as opposed to stab wound (1). A 62-year-old, otherwise healthy man presented to the Emergency Department (ED) with trauma to the left side of the chest that occurred while splitting firewood with an axe. On examination, blood pressure was 120/90 mm Hg, pulse was 68 beats/ min, the respiratory rate was 22 breaths/min, and the oxygen saturation was 98% in room air. There was a 3-mm entrance wound with minimal bleeding found on the left midclavicular line over the nipple. There was no swelling or ecchymosis on the chest wall. The patient was mildly lethargic. Breath sounds were clear bilaterally but heart sounds were diminished. Bedside focused assessment with sonography for trauma (FAST) examination revealed no pneumothorax, no hemothorax, no intraperitoneal fluid, and no pericardial effusion. Chest radiograph and electrocardiogram revealed no detectable abnormalities. Seeing that the patient was obtunded, bedside transthoracic echocardiography (TTE) was performed. The heart was found to be posteriorly displaced due to a hematoma
Figure 1. Massive substernal hematoma (A, white arrows) and metallic foreign body (B, white arrow) in contrast-enhanced computed tomography scan (A, axial section; B, sagittal reconstruction).
1
2
Letters to the Editor
Figure 2. Metallic foreign body thought to have detached from either the axe or nails on the firewood. It is approximately 7 mm in length and has sharp edges.
caused by high-energy penetration, as from a gunshot or stabbing (2). Isolated IMA injuries have delayed consequences like mediastinal hematoma rather than causing acute hemorrhagic shock, because even a completely divided vessel can potentially retract and achieve hemostasis as a result of arterial spasm and hypotension (3). Because the anterior mediastinum is a shallow space, an expanding hematoma caused by IMA injury may result in serious complications (4). The mediastinal hematoma may serve as a threat to hemodynamic stability, not only as a source of blood loss, but also as a potential source of compression of vascular structures such as the heart, and pulmonary arteries (5). A prompt, thorough search and accurate diagnosis of a hematoma is crucial, but early recognition of isolated IMA injury is difficult. Chest radiography, FAST, and TTE have low sensitivity and specificity. Thus, for stable patients, CT scan can be the proper diagnostic tool. If contrast-enhanced CT scan is utilized, an entire series of the IMA can be imaged to elucidate any injury. In contrast to most of the reported cases of isolated IMA injury after penetrating injury, our case is unique with respect to cause of injury. A very minute foreign body transected the LIMA and caused a massive anterior mediastinal hematoma. In conclusion, regardless of the size of causative material in penetrating traumas, all chest wall traumas should be evaluated equally. TTE and CT scan should be the diagnostic modalities of choice.
Figure 3. Active hemorrhage caused by total transection was seen in the midportion of the left internal mammary artery prior to bifurcation.
Safak Alpat, MD, PHD Onur Saydam, MD Hasan Aydin, MD Riza Dogan, MD Department of Cardiovascular Surgery Hacettepe University School of Medicine Ankara, Turkey http://dx.doi.org/10.1016/j.jemermed.2013.08.143
REFERENCES 1. Sharma OP, Blaney J, Oswanski MF, Assi Z, DiSalle R, Latocki V. Stab wound of the neck with contralateral hemo-pneumothorax. J Emerg Med 2010;39:e135–8. 2. Mandal AK, Oparah SS. Unusually low mortality of penetrating wounds of the chest. Twelve years’ experience. J Thorac Cardiovasc Surg 1989;97:119–25. 3. Ritter DC, Chang FC. Delayed hemothorax resulting from stab wounds to the internal mammary artery. J Trauma 1995;39:586–9. 4. Irgau I, Fulda GJ, Hailstone D, et al. Internal mammary artery injury, anterior mediastinal hematoma, and cardiac compromise after blunt chest trauma. J Trauma 1995;39:1018–21. 5. Braatz T, Mirvis SE, Killeen K, et al. CT diagnosis of internal mammary artery injury caused by blunt trauma. Clin Radiol 2001; 56:120–3.
