Posttraumatic Hemothorax and Pneumothorax in a Patient on Oral Anticoagulant

A 58-year-old man on direct oral anticoagulant therapy for paroxysmal atrial fibrillation was involved in a motorcycle accident, resulting in thoracic and head trauma. He had severe acute respiratory failure and underwent endotracheal intubation and invasive mechanical ventilation in the intensive care unit. Total-body computed tomography (CT) showed multiple fractures (several ribs bilaterally, T2 vertebra, and bilateral sacral ala). On the right side, pleural effusion, pulmonary contusion, and thin pneumothorax were found. Prothrombin complex concentrate was administrated to obtain rapid replacement of coagulation factors, followed by placement of a right pleural drain, resulting in dark blood coming out. About 24 hours later, sudden worsening of oxygen parameters occurred as a result of large right pneumothorax. The pleural drain was blocked by clots and was urgently replaced with a larger-bore tube. There was abundant air leakage, which persisted for several days. A digital drainage system helped assess the progressive air leak reduction. The patient improved clinically and was extubated. When bubbling stopped, the second chest tube was removed, and an invasive procedure was no longer needed. This chapter deals with hemothorax and bloody pleural effusions, analog and digital pleural drainage systems, and strategies for the reversal of the effects of anticoagulant drugs.