{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T11:04:55Z","timestamp":1769079895905,"version":"3.49.0"},"reference-count":0,"publisher":"BMJ","issue":"1","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Trauma Surg Acute Care Open"],"accepted":{"date-parts":[[2018,5,30]]},"published-print":{"date-parts":[[2018,6]]},"abstract":"\n \n A 53-year-old man was admitted to our trauma center after sustaining thoracoabdominal injuries, secondary to a rear-end motor vehicle collision. As he stepped out of his vehicle, he was struck by a tractor\u00a0trailer at 55\u00a0mph. The following were the\u00a0initial vital signs on his\u00a0arrival: heart rate 140 beats\/min, blood pressure 142\/80 mm\u00a0Hg, respiratory rate 28 breaths\/min, temperature 36.8\u00b0C, and\u00a0oxygen\u00a0saturation 93%. The\u00a0Glasgow Coma Scale\u00a0score was 15 and the\u00a0Injury Severity Score was 59. He was evaluated and resuscitated per the\u00a0advanced trauma life support\u00a0protocols. The focused assessment with sonography for trauma\u00a0examination was negative. Initial findings included bilateral chest wall and thoracic spine tenderness, subcutaneous emphysema in the chest and neck, and an unstable pelvis. He required bilateral chest tubes and a pelvic binder. CT imaging revealed a left temporal epidural hematoma, multiple facial fractures, a sternal fracture, a left scapula fracture, acromioclavicular fractures, bilateral hemopneumothoraces, pulmonary contusions, extensive pneumomediastinum compressing the right atrium, multiple rib fractures (2\u201310 on the left with a flail segment and 2\u20138 on the right)\u00a0(figure 1), an unstable open-book pelvic fracture which included bilateral superior and inferior pubic rami fractures, sacral and left iliac wing fractures, and symphysis pubis diastasis.<\/jats:p>\n \n Figure 1<\/jats:label>\n \n Three-dimensional CT scan reconstruction demonstrating left-sided flail chest.<\/jats:p>\n <\/jats:caption>\n \n <\/jats:fig>\n The patient developed hypotension and\u00a0severe respiratory distress, and was intubated. ECG revealed no dysrhythmias. Echocardiogram revealed significant left ventricular wall dysfunction consistent with myocardial contusion and right atrial compression. His troponins were also significantly elevated. He required significant resuscitation with crystalloids, blood products and vasopressors. He underwent bronchoscopy, esophagram and upper endoscopy to exclude tracheoesophageal injury, and\u00a0these were negative. On hospital day 2, the patient was hemodynamically stable, and pressors were discontinued. His pelvic fractures were repaired using external fixation and sacral screws. Given his extensive left flail chest, he underwent reconstruction of his left chest wall on hospital day 5. Open reduction and internal fixation of his left ribs, 3\u00a0to\u00a06 anteriorly and 4\u00a0to\u00a07 posteriorly, with titanium plates was performed (figure 2). He had an epidural catheter inserted for analgesia. On postoperative day 2 after chest wall reconstruction, the patient was extubated and resumed enteral feeds. Overnight, the output from the left-sided chest tube changed from serosanguinous to milky. A sample was sent for triglycerides and lymphocyte counts confirming the diagnosis of chylothorax. His chest tube output increased to approximately 2000 mL\/day. A lymphangiogram was performed with Lipiodol to diagnose the location of the chylous leak. It revealed contrast extravasation at the level of T3\u00a0to\u00a0T4. An MRI was also performed to better define the anatomic course of the thoracic duct.<\/jats:p>\n \n Figure 2<\/jats:label>\n \n Postoperative chest X-ray\u00a0demonstrating left chest wall reconstruction.<\/jats:p>\n <\/jats:caption>\n \n <\/jats:fig>\n <\/jats:sec>\n \n What would you do?<\/jats:title>\n \n \n \n Conservative management: placing the patient nulla per os\u00a0(NPO), and starting total parenteral nutrition (TPN), octreotide and midodrine.<\/jats:p>\n <\/jats:list-item>\n \n Thoracic duct embolization by interventional radiology.<\/jats:p>\n <\/jats:list-item>\n \n CT-guided thoracic duct disruption.<\/jats:p>\n <\/jats:list-item>\n \n Thoracotomy with thoracic duct ligation.<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1136\/tsaco-2018-000183","type":"journal-article","created":{"date-parts":[[2018,6,21]],"date-time":"2018-06-21T00:15:20Z","timestamp":1529540120000},"page":"e000183","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":6,"title":["Blunt rupture of the thoracic duct after severe thoracic trauma"],"prefix":"10.1136","volume":"3","author":[{"given":"Samuel R","family":"Brown","sequence":"first","affiliation":[{"name":"Department of\u00a0Surgery, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carlos","family":"Fernandez","sequence":"additional","affiliation":[{"name":"Department of\u00a0Surgery, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert","family":"Bertellotti","sequence":"additional","affiliation":[{"name":"Department of\u00a0Surgery, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Juan Antonio","family":"Asensio","sequence":"additional","affiliation":[{"name":"Department of\u00a0Surgery, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2018,6,20]]},"container-title":["Trauma Surgery & Acute Care Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/tsaco-2018-000183","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,17]],"date-time":"2025-08-17T18:06:56Z","timestamp":1755454016000},"score":1,"resource":{"primary":{"URL":"https:\/\/tsaco.bmj.com\/lookup\/doi\/10.1136\/tsaco-2018-000183"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,6]]},"references-count":0,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2018,6,20]]},"published-print":{"date-parts":[[2018,6]]}},"alternative-id":["10.1136\/tsaco-2018-000183"],"URL":"https:\/\/doi.org\/10.1136\/tsaco-2018-000183","relation":{},"ISSN":["2397-5776"],"issn-type":[{"value":"2397-5776","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,6]]}}}