A 20-year-old man with no remarkable past medical history was brought to the emergency department (ED) of a resource-limited hospital by ambulance with bilateral, anterior thoracic stab-wound lacerations ().\nThe patient was awake and responsive with a Glasgow Coma Scale of 15; he had a heart rate of 84 beats per minute, blood pressure of 90/60 millimeters of mercury, 22 breaths per minute, and oxygen saturation of 97% on room air. He complained of bilateral chest pain and shortness of breath. Physical exam primary survey revealed decreased breath sounds on the left, with bilateral large anterior chest wall lacerations. The left chest laceration had lung parenchyma protruding, and it expanded with each inspiration (). There were no other traumatic injuries or active hemorrhage on further primary survey, and secondary survey was unremarkable.\nCloser examination of the wounds showed the right chest wound at the ninth intercostal space (ICS) with no evidence of exposed lung, and the left chest wound also at the ninth ICS but clearly exposing lung parenchyma. Bedside focused assessment with sonography for trauma (FAST) did not demonstrate a pericardial effusion or intra-abdominal free fluid. The standard blood tests for trauma patients were collected in this patient and were unremarkable, including initial hemoglobin of 13.6 grams (g) per deciliter (dL) (reference range: 12.0 – 16.0 g/dL).\nInitial management included fluid resuscitation with one liter of normal saline (NS), analgesia with ketoprofen and tramadol intravenously, and oxygen facemask at six liters per minute. His blood pressure improved, and he did not require blood products or intubation in the ED. The eviscerated lung portion was left in place and covered with saline-saturated sterile towels. A portable radiograph machine was not immediately available, and CT was not performed because of concerns for clinical instability occurring while in CT. Instead the patient was assessed by the trauma team, which recommended immediate surgical intervention.\nThe patient was taken to the operating room (OR), and under general anesthesia the chest was explored using a left anterolateral thoracotomy at the fifth ICS. Injury to the heart, great vessels, and diaphragm was ruled out; surgical exploration revealed only a small amount of hemothorax. The left lung had no signs of laceration, necrosis, or thrombosis. The eviscerated portion of the lung was determined to be the lingula. After confirming the integrity of the vasculature, the lingula of the lung was retrieved back into the left hemithorax, the left hemithorax was irrigated with two liters of NS, and the patient was ventilated by the anesthesia team to assess the anatomic integrity of the parenchyma. Once the lung showed no signs of air leakage during the insufflation test, the NS irrigation and secretions were suctioned, and closure of the left thoracotomy incision was performed. A thoracostomy tube was placed in the left hemithorax and attached to underwater seal drainage. After 48 hours, a chest radiograph was obtained for evaluation of re-expansion of the lung ().\nThe patient was kept under observation for 12 hours in the postoperative care unit and spent the rest of his hospital stay in the general surgery ward, not requiring intermediate or intensive care unit admission. He received tramadol for analgesia, prophylactic antibiotics with ampicillin-sulbactam three grams intravenously every six hours for seven days as an in-patient, and then continued with amoxicillin-clavulanic acid 875/125 milligrams orally every 12 hours for three days upon hospital discharge. He had an uneventful postoperative course, with a fully expanded lung on postoperative radiograph and steady functional and cosmetic improvement at 15- and 30-day follow-up outpatient visits.
A 65 years old man presented to the emergency department with left-sided flank pain that started after a popping sound was heard following a cough spell. There was no history of trauma. He is an active smoker, and his past medical history includes congestive heart failure, hypertension, coronary artery disease, diabetes mellitus, chronic pain secondary to lumbar disc disease requiring multiple epidural injections and multiple orthopedic procedures including knee replacement and rotator cuff repair. He did not have any history of surgical procedures on his chest wall. His medications included hydrochlorothiazide, lisinopril, metoprolol, metformin, aspirin, clopidogrel and diclofenac. Examination was negative for any tenderness or deformity on the left flank. Electrocardiogram was unremarkable, and chest X-ray was negative for any acute pathology. He was discharged home on pain medications with a diagnosis of muscular spasm. A few days later, he represented with non-resolution of symptoms. This time on examination he was found to have a large hematoma of the left flank tracking inferiorly to the left gluteus. There was no fullness, tenderness or crepitus on palpation. Computed tomography (CT) thorax revealed a chest wall defect on the left side between eighth and ninth ribs with herniation of lung tissue (Fig. , red arrow) and a 5 cm × 3 cm hematoma but did not reveal any fractures. He was managed conservatively with pain medications as there was no evidence of vascular compromise to the lung tissue. A month later, he presented again with poorly controlled chest pain and shortness of breath. Chest X-Ray showed stable herniation of lung tissue with widening of eighth intercostal space (Fig. ). Subsequent CT thorax revealed progression of lung herniation (Fig. , red arrow) associated with left lower lobe atelectasis, alongside acute, displaced fractures of left eighth and ninth ribs (Fig. , green arrow). No surgical repair was performed based on a recent positive stress test and his elevated perioperative risk of cardiovascular events. He was discharged on opioid pain medications. At the follow-up visit, he still continues to have pain in the left lower chest, even though he is on a high dose of pain medications. We also tried intercostal nerve blocks, which seems to be ineffective in his case. There appears to be some respiratory compromise unsure whether secondary to chronic heart failure or ‘lung herniation fracture’.