Kikukawa Motohiro, Kuriyama Akira
Emergency and Critical Care Center, Kurashiki Central Hospital, Japan.
Ann Med Surg (Lond). 2021 Sep 13;70:102854. doi: 10.1016/j.amsu.2021.102854. eCollection 2021 Oct.
Placement of an intercostal chest drain (ICD) is an essential procedure in the management of patients with chest injuries. However, ICD placement can have complications. Here, we report a case of massive hemothorax due to injury of an anonymous vein associated with ICD placement.
An 84-year-old man with chronic right pleural effusion from pleuroperitoneal communication presented with dyspnea after a fall. An ICD was placed in the right seventh intercostal area on the middle axillary line. He later complained of chest pain and dyspnea again due to right pneumothorax, and massive hemorrhagic pleural effusion was drained from an additionally placed ICD. A contrast-enhanced computed tomography scan showed that bleeding from the parietal pleura traveled along the first ICD and dropped into the intrapleural space. Intraoperatively, there was intramuscular venule bleeding from the right serratus anterior muscle, which was then ligated to stop the bleeding.
An optimal area to place an ICD is termed the "safety triangle", which is determined by the pectoralis major, latissimus dorsi, and the level of the nipples and the base of the axilla. In this case, the ICD was placed in the seventh intercostal area, which is more than two intercostal distances inferior to the 'safety triangle'.
This case suggested that, even though the vessel was small, a massive, life-threatening hemothorax can occur if an injury is caused by ICD placement. Knowledge of the anatomy necessary for placing an ICD should be reinforced.
肋间胸腔引流管（ICD）置入是胸部损伤患者治疗中的一项重要操作。然而，ICD置入可能会出现并发症。在此，我们报告一例因ICD置入导致无名静脉损伤引起大量血胸的病例。
一名84岁男性，因胸膜腹膜交通导致慢性右侧胸腔积液，跌倒后出现呼吸困难。在腋中线右侧第七肋间区域置入了一根ICD。随后，他因右侧气胸再次出现胸痛和呼吸困难，通过额外置入的ICD引出了大量出血性胸腔积液。增强计算机断层扫描显示，壁层胸膜出血沿第一根ICD下行并落入胸腔内。术中发现右侧前锯肌有肌内小静脉出血，随后进行结扎止血。
放置ICD的最佳区域称为“安全三角”，由胸大肌、背阔肌以及乳头水平和腋窝底部确定。在本病例中，ICD放置在第七肋间区域，比“安全三角”低两个以上肋间距离。
该病例表明，即使血管较小，但如果ICD置入造成损伤，也可能发生大量危及生命的血胸。应加强对放置ICD所需解剖知识的掌握。
