A 79-year-old male admitted to the emergency department with persistent pain on the posterior right chest wall after a fall 5 days prior. He has history of heart failure, hypertension, type 2 diabetes mellitus, aortoiliac aneurysm correction, and biological mitral valve replacement 10 years ago. Prior to admission, his medications included nifedipine, clonidine, timolol, and metformin. Vital signs were normal and physical examination showed bruising along the right costal margin. Pulmonary sounds were absent in the right hemithorax. Computed tomography (CT) scan reported non-displaced transverse fractures in the middle third of the right 7th, 8th, 9th, and 12th costal arches and depressed rib fractures of the 10th and 11th arches, along with a massive hemothorax (Fig. 1A). Treatment included closed thoracostomy, analgesia, and respiratory therapy, which led to improvement. The chest tube was withdrawn, and the patient was discharged on day three.
Three days later he returned with symptoms of dyspnea and bleeding from the thoracostomy site. CT angiography demonstrated a small residual clotted hemothorax (Image 1B). Given the patient's extensive medical history and underlying health conditions, a conservative management approach was taken. The patient's condition deteriorated, resulting in acute heart failure, new-onset atrial flutter requiring electrical cardioversion with return to sinus rhythm, ventilatory failure, and renal failure. Signs of shock were evident, possibly due to infection indicated by elevated leukocyte levels and acute-phase reactants, prompting suspicion of a secondary hemothorax infection. On day 29 post-trauma, right lung decortication by Video-assisted thoracoscopic surgery (VATS) was performed, uncovering lung entrapment, old clots, and no active pleural bleeding. Post-surgery, the patient experienced melena and upper gastrointestinal bleeding, managed with blood transfusions and endoscopic intervention. Post-surgical care continued at the intensive care unit. Patient´s condition improved slowly, and he initiated physical rehabilitation.
On day 62 the patient suddenly presented hypotension, decreasing levels of hemoglobin, and hyperlactatemia. CT angiography indicated a significant hemothorax with active bleeding from the right intercostal artery adjacent to a known rib fracture (Image 2). The patient underwent a second VATS, revealing an active jet bleeding from the intercostal artery successfully managed through selective ligation (video 1).
The patient's condition improved gradually, leading to the discontinuation of invasive mechanical ventilation and vasopressor support, allowing physical and pulmonary rehabilitation. However, the patient's extended hospitalization and physical decline led to the development of a sacral ulcer, necessitating debridement and cleansing. Afterward, clinical trajectory was characterized by abdominal pain and distension, hypotension, altered mental status, and prolonged capillary refill time. A positive culture for Clostridium difficile was found in fecal samples. This triggered septic shock resulting in the patient's demise thirteen days after the last VATS.