Management Challenges in Trauma-Induced Coagulopathy: A Case Report of Hemothorax Requiring Reoperation

Abstract

BACKGROUND Coagulopathy caused by trauma itself is defined as trauma-induced coagulopathy (TIC). The pathophysiology of TIC is considered to consist of coagulation activation, hyperfibrinolysis, and consumption coagulopathy, similar to disseminated intravascular coagulation (DIC). This report describes a 68-year-old man with a history of epilepsy presenting with TIC associated with multiple traumatic fractures and hemothorax. CASE REPORT A 68-year-old man with a history of epilepsy fell while working on a second-floor roof and had right rib fractures (6th to 12th rib), right hemothorax, right clavicle fracture, right elbow fracture, and pelvic fractures. The right hemothorax became exacerbated and he went into shock. We performed the emergency surgery 5 hours after the trauma. Although circulation dynamics became stable and the discharge of chest drainage became thinned at postoperative day (POD) 1 while administering blood transfusions and tranexamic acid, hemoglobin remained below 8 g/dl, platelet count was below 60 000/µl, and prothrombin time - international normalized ratio (1.22) remained prolonged. Furthermore, the right hemothorax became exacerbated and re-operation was performed on the evening of POD2. Oozing hemorrhages from multiple rib fractures were observed. Although hemostatic management was performed with electrocautery and ultrasound energy devices, the hemorrhage could not be completely managed, so hemostasis was secured using hemostatic materials. CONCLUSIONS The pathophysiologic mechanism of TIC has been emphasized as being different from that of DIC, and management of severe traumatic patients with TIC should be based on an understanding of the pathophysiology of TIC.

Figure 1.

Imaging findings at the time of trauma. Computed tomography shows right rib fractures (A), right hemothorax (B), right clavicle fracture (C), right elbow fracture (D), and pelvic fractures (E).

Figure 2.

Imaging findings before and after re-operation. Chest computed tomography shows exacerbation of the right hemothorax (A). The right hemothorax did not become exacerbated, while left-lung pneumonia occurred in the morning of postoperative day (POD) 2 (B). The right lung field of chest X-ray shows worsening permeability on the evening of POD 2 (C). The right hemothorax was not exacerbated and left pneumonia gradually improved 7 days after re-operation (D).

Figure 3.

The course of the treatment. Red cell concentrate (RCC) and fresh frozen plasma (FFP) transfusions were administered from intraoperatively. After surgery, unstable circulation dynamics was continued, and continuous dose of noradrenaline was added, while platelet concentrate (PC) transfusion and tranexamic acid (TXA) were also administered in addition to RCC and FFP transfusion. Hemoglobin (Hb) and platelet (Plt) count slowly declined and prothrombin time-international normalized ratio (PT-INR) was extended (PT-INR 1.54), and then RCC, FFP, and PC transfusion and TXA were also administered. Left-lung pneumonia occurred on POD 2 and antibacterial drugs were administered [cefazolin sodium (CEZ) 2 g/day, meropenem hydrate (MEPM) 1.5 g/day, ceftriaxone sodium hydrate (CTRX) 2 g/day]. However, oxygenation suddenly became worse and a chest X-ray showed worsening permeability of the right lung field on the evening of POD 2. We decided there was exacerbation of the right hemothorax, and performed the re-operation. Although the circulation dynamics continued to be stable after the re-operation, Hb and Plt count remained low and PT-INR extension continued, and then RCC, FFP, PC transfusions, and TXA were also administered after the re-operation.