1. Right traumatic hepatothorax
ISAAC OKYERE MD FWACS
Cardiothoracic and Vascular Surgeon
KOMFO ANOKYE TEACHING HOSPITAL KUMASI

2. DEMOGRAPHY J.J 44yr old male
Cattle farm help, from Agogo .drinks alcohol and presented on the 26/02/16 at 1420hrs as a referral from Agogo Hospital as a case of Right haemothorax with persistent abdominal and right chest pains .Prior 2 days he had been attacked unprovokedly by a wild bull
Hurled into the air thrice, dropped on the ground and stomped on while supine in the chest and upper abdomen by the bull

3. Sustained lacerations to thorax anterolateral
RT Chest and RT upper quadrant pain
Initially seen at a peripheral facility
Transfused 2 units of whole blood. Referral HB 10.9

4. He had :
Shortness of breath
Chest pain
Cough ( non- productive)
right chest and upper abdominal pains

5. Other systems
Not significant

6. Middle aged man, looks well, not in acute distress, mildly pale, not jaundiced, afebrile, well hydrated
AIRWAY + C-SPINE GCS:15/15
Talking clearly
Trachea :midline
C-spine : nontender

7. Significant FINDINGS
Deep puncture wound noted on lateral aspect of right hemithorax
Superficial laceration on left hemithorax(lateral)
Limited chest expansion on the right hemithorax
Chest compression tenderness + ( over right hemithorax)
Crepitance over anterior thorax RT>>> LT to navel
Decreased breath sounds over right hemithorax
Linear superficial clean laceration on posterolateral aspect of the left thigh

8. Soft, non-distended
Tenderness with guarding in right upper quadrant
BS + normoactive

9. INTERVENTION
Clinical diagnosis :Thoracoabdominal injury with Haemopneumothorax and Haemoperitoneum
Started on high flow oxygen via intranasal cannula
Size 32FG chest tube passed in 4ICS draining air mainly
E-FAST – normal.

10. LAB.RESULTS
FBC HB 7.6 L WBC 6.68 N 83% H L11.5% PLT 107 L ELECTROLYTES Within normal limits Globulin 15.9 L RFTS UREA 7.57 CREATININE 116 BUN/CR 30.5

11. PLAN Maintain on O2 support with SpO2 q2hrly IVF Maintenance
Analgesics
Antibiotics
Wound care

12. CHEST AND ABDOMINAL XRAY

13. ABDOMINOPELVIC USG Normal liver, though liver injury not excluded
Right Pleural Effusion
Concern raised with Radiologists about finding on lower zone opacity
Diaphragm said to have been visualized and normal

14. PROGRESS
Next day of admission. Chest drainage noticed to have become tinge with blood with no appreciable increase in quantity.
Hb had dropped from 7.9 to 6.9.
Transfused 2 units whole blood.
SpO2 still 99% on nasal prongs
Abdomen- no changes from previous findings
CT THORACIC SCAN REQUESTED

15. CHEST AND ABDOMEN CT

16. RUPTURED RIGHT HEMIDIAPRAGMATIC .
SURGERY :EMERGENCY EXPLORATORY THORACOTOMY

17. Complete rupture of right hemidiaphragm
FINDINGS
Complete rupture of right hemidiaphragm
Laceration of liver capsule with partial herniation of liver into right hemithorax
Fracture of the right 7th rib
Normal intrathoracic organs: lungs, pericardium

18. INTRA- OP

23. POST-OP Patient stable on ward and discharged home on
POD 10 for routine follow-up at the clinic

24. CONCLUSION
1.Diaphragmatic injuries in penetrating trauma can be difficult to diagnose
2.Once the diagnosis is made, their management is straight forward .
3.Any penetrating injury at the nipple line or below should be considered to have the potential for both abdominal and thoracic injury and traversal of the diaphragm.

25. 4.Therefore exploratory laparotomy is recommended in patients with penetrating wounds inferior to the fourth inter costal space anteriorly ,sixth interspace laterally or eighth posteriorly because of the contour and insertion of the diaphragm.

26. 5.The challenge of management is how to diagnose it and the repair is usually via thoracotomy in right ruptures and chronic stages and via laparotomy in the acute stage. Non-absorbable sutures in an interrupted fashion is preferred.

27. FOLLOW UP Patient is fine and without any sequelae.
“Still a happy cattle farm help and still enjoys beef.”

28. THANK YOU