Lung resection for extensive lung injury causing severe hemorrhage

Lung resection for extensive lung injury causing severe hemorrhage ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O)Lung resection for extensive lung injury causing severe hemorrhageBG Jayawickrama1, WMASB Wasala2, MVG Pinto3, KB Galketiya4* 1Surgical registrar, Teaching Hospital, Peradeniya, Sri Lanka 2Lecturer, Department of Anesthesia, Faculty of Medicine, Peradeniya, Sri Lanka3Consultant anesthetist/ Senior lecturer, Department of Anesthesia, Faculty of Medicine, University of Peradeniya, Sri Lanka4Consultant surgeon/ Senior lecturer, Department of Surgery, Faculty of Medicine, University of Peradeniya, Sri Lanka*Corresponding author email: [email protected] to cite this article: BG Jayawickrama, WMASB Wasala, MVG Pinto, KB Galketiya. Lung resectionfor extensive lung injury causing severe hemorrhage. IAIM, 2015; 2(3): 151-154.Available online at www.iaimjournal.comReceived on: 02-02-2015 Accepted on: 09-02-2015AbstractWe have presented here a case of a twenty three year old male who successfully recovered of amassive right lung injury by rapid transport, insertion of inter costal drain, emergency thoracotomyfor resection of upper and middle lobes and post operative intensive care.Key wordsHemothorax, Thoracotomy, Lung injury, Lung resection.Introduction severe lung injury who survived following resection of upper and middle lobes.Rapid transport to hospital, primary survey andresuscitation, secondary survey and surgical Case reportintervention as required are lifesaving in major A 23 years old male was brought into emergencytrauma [1, 2]. In chest injury recognition of treatment unit following an accident while ridinghemo-pneumothorax and insertion of in a motor cycle. He was admitted within thirtyintercostals (IC) tube in emergency room are minutes. His airway was intact, tachypnoeic withrequired. In face of an initial return of more than a respiratory rate of thirty and a blood pressure1500 ml of blood from the IC tube emergency of 70/50 mmHg. He had clinical evidence of athoracotomy is required [3]. Thoracotomy is right hemothorax and a chest drain insertedrequired only in 10-15% [4]. We have presented which drained 1500 ml of blood. He washere a case report of a young male who conscious with no other injuries. He was startedpresented with a massive hemothorax due toInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 151Copy right © 2015, IAIM, All Rights Reserved.

Lung resection for extensive lung injury causing severe hemorrhage ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)on fluid resuscitation but blood pressure ventilation failed and a tracheostomy wasremained low with continued bleeding through performed on the seventh post operative day.the chest drain. FAST scan revealed no intraperitoneal bleeding. He was brought into The patient was started on naso-gastric feedingemergency operating theatre by which time the from the first post operative day. Followingreturn into inter costal bottle was 2000 ml. An tracheostomy patient was started on oralinter costal tube was inserted to left side as well feeding but had to abandon due to aspiration.which drained about 500 ml. Blood transfusion He was evaluated by the ENT team and rightwas started and emergency thoracotomy was vocal cord palsy revealed.performed, patient being intubated with a singlelumen tube. Right lateral thoracotomy revealed Patient was transferred to high dependencyblood filled hemithorax of about 500 ml and after ten days. Chest physiotherapy wassevere bleeding from shattered upper and continued. The tracheostomy was removed twomiddle lobes of the right lung. Compression was weeks after its insertion. Oral liquids continuedapplied to get some control of the bleeding. The to cause aspiration. However he tolerated semi-damage was more severe in the upper lobe with solids. Later he managed to take solids and wascontinued bleeding when compression was capable of having liquids after about five weeksreleased. We decided to resect the upper lobe from injury. He was discharged six weeks afterand achieve suture control of the middle lobe. admission by which time had recovered of his hoarse voice significantly.Following resection of the upper lobe, thedamaged middle lobe continued to bleed and Discussionsuture control failed requiring lobectomy. The Hemothorax with an initial return of more thanpatient was transfused 15 units of blood. Fresh 1500 ml is an indication for thoracotomy [3]. Thefrozen plasma and platelet transfusions were patient under discussion had a massive lungdone as required. injury accounting for the bleeding. The methodsThe patient had a cardiac arrest towards the end to control lung hemorrhage are suturing,of the procedure which was successfully lobectomy or pneumonectomy [4]. We had tomanaged. He was admitted to intensive care resort to resection of upper and mid lobes ofunit and ventilated. Right inter costal tube right lung as suturing did not control bleeding.drained 500 ml during the first six hours which Patient required 15 liters of blood duringdecreased later. The cardiovascular and surgery. Thoracotomy was started with a bloodrespiratory parameters were stable, initially with pressure of 60/40. Damage control resuscitationaddition of inotropes. He had a good urine plays a key role in the management of such aoutput. critically ill patient. It includes early bloodPatient’s post-operative chest X-ray revealed product transfusion, immediate arrest and/orfractured ribs on right side from first to 9th rib. temporization of ongoing hemorrhage,The left inter costal tube was removed after 48 hypotensive resuscitation (permissivehours and the right after one week. Patient was hypotension) and restoration of blood volumeextubated the next day but required re- and physiologic stability by correctingintubation. Several attempts to wean off coagulopathy, acidosis and hypothermia [5]. Tissue trauma, shock, hemodilution, hypothermia, acidemia and inflammation allInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 152Copy right © 2015, IAIM, All Rights Reserved.

Lung resection for extensive lung injury causing severe hemorrhage ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)play key trigger roles in the acute coagulopathy more efficient suction [8, 10, 11]. Thereforeof trauma in patients with shock which is further early tracheostomy is recommended for patientsaggravated by massive transfusion [5, 6]. requiring prolonged ventilation and lateTherefore current massive transfusion protocol tracheostomy more than 21 days afterincludes delivery of 1:1:1 ratio of RBC: fresh intubation is associated with prolonged weaningfrozen plasma: platelets and monitor for and periods and low rates of successful weaning [8,correct hypothermia, hypofibrinogenemia, and 10]. Therefore tracheostomy of this patient waselectrolyte disturbances such as hypocalcemia performed on the seventh post-operative day.and hyperkalemia [6]. Cardiac arrest of thepatient towards end of the procedure is likely to Nutrition was maintained through naso-gastricbe as a consequence of cardiac depression (NG) tube from day one. Aspiration of liquidssecondary to such electrolyte and acid base delayed oral feeding and NG feeding had to bedisturbances. continued. He managed to tolerate semi solids and then solids before he could take liquidsThe patient was managed with double lung without aspiration. Incidence of recurrentventilation. Literature gives support for both laryngeal nerve palsy leading to swallowingsingle and double lung ventilation for lung difficulties has been reported following bluntresection in trauma [4, 7]. The evidence to chest trauma with tracheobronchial disruptionsupport lung isolation is to prevent aspiration of [12] and pneumonectomy [13].blood to the ventilated lung. However, properplacement of a double lumen tube especially Conclusionwithout having a flexible bronchoscope inemergency setting is difficult. In this patient the This case illustrates the importance of rapidendotracheal tube was frequently sucked to control of massive hemorrhage in chest traumaminimize blood aspiration and oxygen saturation by timely transport, quick assessment andwas well maintained. resuscitation, emergency surgical intervention with anesthetic support to save life. The post operative care should be intensive to overcomeThe patient required prolonged ventilator multiple problems related to major trauma.support possibly due to multiple rib fractures,loss of lung volume and right vocal cord palsy. ReferencesProlonged ventilation is associated withventilator-associated pneumonia (VAP) [8, 9]. 1. Mackowski MJ, Barnett RE, HarbrechtAcute Respiratory Distress Syndrome (ARDS), BG, Miller KR, Franklin GA, Smith JW,pulmonary embolism, barotrauma, and Richardson JD, Benns MV. Damagepulmonary edema are also among the control for thoracic trauma. Thecomplications that can occur in patients American surgeon, 2014; 80(9): 910-3.receiving mechanical ventilation [9]. 2. Desforges JF, Trunkey D. Initial treatment of patients with extensiveTracheostomy is an adjunct to continued trauma. N Engl J Med, 1991; 136: 5.mechanical ventilator support. Tracheostomy 3. Jones RK, Jurkovich GJ, Nathens AB,has several advantages over endotrachealintubation, including lower airway resistance, Shatz DV, Brundage, Wall MJ, Engelhardtsmaller dead space, less movement of the tube S, Hoyt DB, Holcroft J, Knudson MM. Timing of thoracotomy for hemorrhagewithin the trachea, greater patient comfort andInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 153Copy right © 2015, IAIM, All Rights Reserved.

Lung resection for extensive lung injury causing severe hemorrhage ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)after trauma. Arch Surg., 2001; 136(5): mechanical ventilation. N Engl J Med,513-518. 2006; 355: 41-50.4. Weigolt AJ. Pulmonary resection for 10. Heffner JE, Miller KS, Sahn SA.trauma. Rob and Smith Operative Tracheostomy in the intensive care unit.surgery. 4th edition. Butterworths, 1989; Part 1: Indications, technique,p. 311-317. management. Chest, 1986, 90: 269-274.5. Ball CG. Damage control resuscitation: 11. Diehl JL, El Atrous S, Touchard D,History, theory and technique. Can J Lemaire F, Brochard L. Changes in theSurg., 2014; 57(1): 55–60. work of breathing induced by6. Hess JR, Brohi K, Dutton RP, et al. The tracheotomy in ventilator-dependentcoagulopathy of trauma: a review of patients. Am J Respir Crit Care Med,mechanisms. J Trauma, 2008; 65: 748– 1999; 159: 383-38.54. 12. Baumgartner F, Sheppard B, et al.7. Richter T, Ragaller M. Ventilation in Tracheal and main bronchial disruptionschest trauma. J Emerg Trauma Shock, after blunt chest trauma: Presentation2011; 4(2): 251–259. and management. The Annals of8. Hsu CL, Chen KY, Chang CH, Jerng JS, Yu thoracic surgery, 1990; 50(4): 569-574.CJ, Yang PC. Timing of tracheostomy as a 13. Carew JF, Kraus DH, Ginsberg RJ. Earlydeterminant of weaning success in complications. Recurrent nerve palsy.critically ill patients. Critical Care, 2005; Chest Surg Clin N Am., 1999; 9(3): 597-9: R46-R52. 608.9. Kahn JM, Goss CH, Heagerty PJ, et al.Hospital volume and the outcomes ofSource of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 154Copy right © 2015, IAIM, All Rights Reserved.