A 42-year-old man is brought to the emergency department 35 minutes after being struck by a car while crossing the intersection. The paramedics found him hypotensive and intubated him in the field for respiratory distress. After resuscitation with 2 liters of normal saline, his blood pressure is 110/80 mm Hg and pulse is 90/min. There is diffuse bruising across the chest, and the right lower leg is visibly deformed. CT scan of the head, cervical spine, and abdomen are normal. CT scan of the chest reveals bilateral, mildly displaced rib fractures with underlying pulmonary contusions and a right-sided pneumothorax. A chest tube is placed. The patient undergoes open reduction and internal fixation of right tibial and fibular fractures and is extubated following surgery. One day later his chest tube is draining turbid, green fluid. Repeat chest-x ray shows resolution of the pneumothorax but there is a new right-sided pleural effusion. Which of the following is the most likely diagnosis?

Question

A 42-year-old man is brought to the emergency department 35 minutes after being struck by a car while crossing the intersection.  The paramedics found him hypotensive and intubated him in the field for respiratory distress.  After resuscitation with 2 liters of normal saline, his blood pressure is 110/80 mm Hg and pulse is 90/min.  There is diffuse bruising across the chest, and the right lower leg is visibly deformed.  CT scan of the head, cervical spine, and abdomen are normal.  CT scan of the chest reveals bilateral, mildly displaced rib fractures with underlying pulmonary contusions and a right-sided pneumothorax.  A chest tube is placed.  The patient undergoes open reduction and internal fixation of right tibial and fibular fractures and is extubated following surgery.  One day later his chest tube is draining turbid, green fluid.  Repeat chest-x ray shows resolution of the pneumothorax but there is a new right-sided pleural effusion.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d8ef_708c_bc81_135f8f4bb7a1_MD0003_00 The injury pattern of pedestrians struck by motor vehicles often includes lower-extremity trauma (from bumper impact) accompanied by thoracic trauma (± head/upper extremity trauma from rolling onto the hood). Blunt thoracic trauma can rapidly increase intraesophageal pressure enough to rupture the esophagus. This patient has turbid green drainage (gastrointestinal contents) into his chest tube following blunt chest trauma, most consistent with esophageal perforation (EP). EP may present with severe chest pain (easily missed if attributed to concurrent chest injuries [eg, rib fractures]) and symptoms/signs related to leaked esophageal air (eg, pneumothorax, pneumomediastinum, subcutaneous emphysema) or gastrointestinal fluid (eg, pleural effusion). These manifestations may not be immediately evident until content (eg, pleural fluid) accumulation increases. If pleural fluid analysis is performed in the setting of EP, it typically shows low pH and high salivary amylase and may show food particles. Esophagography or CT scan with water-soluble oral contrast is the gold standard for confirming EP. Management includes emergent surgical consultation, restriction of all oral intake, and intravenous antibiotic and proton pump inhibitor administration. (Choice A) Bronchopleural fistula can occur following chest trauma but is most common following lung resection. The abnormal flow of inhaled air into the pleural space would cause persistent air leak into the chest tube drainage system rather than green fluid. (Choice B) Diaphragmatic rupture can occur after blunt thoracoabdominal trauma due to a sudden and unequal increase in pressure. However, chest x-ray typically reveals elevated hemidiaphragm or migration of abdominal contents into the thoracic cavity rather than pleural effusion. (Choice D) Blunt chest trauma may cause hemothorax if lung parenchyma or intercostal vessels (eg, rib fractures) are injured. Hemothorax appears on chest x-ray as a pleural effusion; however, drainage would be bloody, not green. (Choice E) Trauma (especially lower extremity) and surgery increase risk of pulmonary embolism. Acute pulmonary embolism with pulmonary infarction can cause an inflammatory, exudative pleural effusion, but the fluid is not typically green. Educational objective: Blunt thoracic trauma can cause a sudden increase in intraesophageal pressure sufficient to rupture the esophagus. If gastrointestinal contents leak from the esophagus into the pleural space, pleural effusion results, and fluid analysis typically reveals unusual color (eg, green), low pH, and high amylase. References: Esophageal perforation. (http://www.ncbi.nlm.nih.gov/pubmed/24267495) Management of esophageal injuries secondary to trauma. (http://www.ncbi.nlm.nih.gov/pubmed/28648409)

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