Tension Pneumopericardium In Blunt Thoracic Trauma

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InternationalJournalofSurgeryCaseReports24(2016)188–190

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

Tension

pneumopericardium

in

blunt

thoracic

trauma

Antonio

Fernando

Rolim

Marques

∗

,

Lizianne

Hermogenes

Lopes,

Marcela

dos

Santos

Martins,

Cesar

Vanderlei

Carmona,

Gustavo

Pereira

Fraga,

Elcio

Shiyoti

Hirano

TraumaDivision,DepartmentofSurgery,UniversityofCampinasTeachingHospital,FacultyofMedicalSciences,UniversityofCampinas,Campinas,SP, Brazil

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Articlehistory:

Received25January2016

Receivedinrevisedform29April2016 Accepted29April2016

Availableonline6May2016 Keywords:

Pneumopericardium Tensionpneumopericardium Cardiactamponade Shock

Bluntthoracictrauma Macklineffect

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INTRODUCTION:Pneumopericardium,deﬁnedasthepresenceofgasinthepericardialsac,isarare con-ditioncausedmostlybytrauma.Tensionpneumopericardiumisacauseofhemodynamicinstability; hence,itconsistsinalife-threateningsituationandshouldberegardedinbluntchesttrauma.

CASEREPORT:A51-year-oldmalewasvictimofa4mfallandburial.Hewasstableuponadmission andpresentedasimplepneumopericardiumandpneumomediastinumonCT.Whilebeingsubmitted toanupperdigestiveendoscopyhepresentedrespiratoryfailureandhadtobeintubated,suddenly evolvingtoshock.Hewaspromptlyreferredtotheoperatingroom;apericardialwindowconﬁrmed tensionpneumopericardiumandimmediatelyhemodynamicstabilitywasrestored.Apericardialdrain wasplacedandkeptfor15days.Hewasdischargedatthe18thdaypost-traumaafterasatisfactory recoveryatthetraumaICU.

DISCUSSION:Bluntthoracictraumacausespneumopericardiumbyvariousmechanisms.Tension pneu-mopericardiumisapossibleoutcome,probablyrelated topositive-pressureventilation.Itleadsto hemodynamicinstabilityandrequiresimmediatedecompressionandplacementofapericardialdrain.

1. Introduction

Pneumopericardiumisthepresenceofgasinthepericardialsac. Themajoretiologyistrauma,mostofwhichbluntchesttrauma

[1,2].Itisararecondition,associatedwithahighmortalityrate(up to57%)duetoitsseverityperse,whencausingcardiactamponade, ortoassociatedtrauma,consideringitisgenerallyfoundin high-energyaccidents[1].

AccordingtoCapizzietal.’sreviewofpneumopericardium fol-lowingblunttraumareports from1931to1995,comprising 32 patients,37%developedtensionpneumopericardium,mostofthem associatedwithmechanicalventilation[3].Thesamepercentage ofhemodynamicinstabilitywasfoundinCummingsetal.’s 252-patientseriesofpneumopericardiumofvariousetiologies[1].

Tensionpneumopericardiumpresentsclinicallywith increas-ing respiratory distress, increased central venous pressure and hypotension.Heartsoundsmaybecomeattenuated.Inmostcases,

Abbreviations:BP,bloodpressure;BPM,beatsperminute;FAST,Focused Assess-mentwithSonographyforTrauma;ICU,IntensiveCareUnit;PO,post-operativeday; UDE,UpperDigestiveEndoscopy.

∗ Correspondingauthorat:DepartmentofSurgery,FacultyofMedicalSciences, StateUniversityofCampinas(UNICAMP),Zipcode13083-970Campinas,SP,Brazil.

E-mailaddress:[email protected]

(A.F.RolimMarques).

chestX-rayexhibitsairsurroundingtheheart,outlinedbyathin stripeconsistingofthepericardiumanditsassociatedstructures. Though, a normal X-ray does not excludepneumopericardium

[1,4].

Although being a relevant cause of shock in trauma, pneu-mopericardiumisrarelyregardedduringinitialtraumaassessment, whichdelays life-savingimmediatemeasuresand proper treat-ment. Moreover, its management is not largely known by practitioners,sincethisconditionisoftenneglectedinemergency protocols due to its rareness. This article brings pneumoperi-cardiumtolight,reinforcingtheimportanceofconsideringitwithin thedifferentialdiagnosisofshockinblunttrauma,remarkingits managementandaddingupourexperiencetothissubject’sscarce literature.ThisreportcomplieswiththeCAREguidelines,ﬁrming itstransparencyandaccuracy[5].

2. Casereport

Thepatient wasa 51-year-oldmale, mason, whosuffered a work accident in thebuilding site–a 4m highfall followed by burial.Hemodynamicallystableandconsciousatthescene,hewas broughttoourtertiaryhospitalbyrescuehelicopter.Onadmission, hepresenteddecreasedbreathsoundsbilaterally,thoracic subcu-taneousemphysema,chestpain,breathingrateof22,peripheral saturationof87%,whichincreasedto93%withsupplementary

oxy-http://dx.doi.org/10.1016/j.ijscr.2016.04.052

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Fig.1.Computedtomographyscansonarrival,axialandcoronalplanes.Anexpressivenon-tensionpneumopericardiumispresent.Pneumomediastinum,subcutaneous emphysemaandrightlungcontusioncanalsobenoticed.

gen,heart rateof92bpm,bloodpressure(BP)of97×70mmHg and a negativeFAST(Focused AssessmentwithSonography for Trauma).

A computer tomography showed bilateral lung contusion; minorpneumomediastinum;anexpressivepneumopericardium; pubicsymphysis disjunction;and fractures ofthesternum, left clavicle,rightscapula,leftischiopubicandiliopubicrami. Pneu-mothorax and abdominalinjuries wereexcluded. Thefractures wereassessed bytheorthopedic team, which consideredthem stableandorientedaconservativemanagement.

In the emergency department, 15h after admission, the patient presented tachypnea during upperdigestive endoscopy (UDE),requiringorotrachealintubation,followedbyhypotension, increaseofthesubcutaneousemphysemaandclinicalsuspicionof rightpneumothorax,immediatelydrained,thoughnoairescape wasfoundduringtheprocedure. Hemodynamicinstability per-sisted (BP80×50mmHg)and hewaspromptly referredtothe operatingroom,whereapericardialwindowwasperformed,in which the escape of a large amount of air was verified, fol-lowed by immediate restoration of hemodynamic stability (BP 130×80mmHg).Atubulardrainwasplacedinthepericardialsac andthepatientwassubmittedtoafiberbronchoscopy.UDEand fiberbronchoscopyshowednoabnormalities(Fig.1).

Following the procedure, the patient was admitted to the TraumaIntensiveCareUnit(ICU)maintaininghemodynamic sta-bilityandfunctioningdrainsinunderwaterseal.Thepericardialsac drainpresentingairbubblingwasconnectedtoasuctionsystem. Thepatientwasextubatedonthefourthpostoperativeday(PO), whenthesuctionsystemwasdisconnected.Aradiographicrelapse ofthepneumopericardiumwasveriﬁedfourdayslater, demand-ingadditional48hundersuction.Onthe13thpostoperativeday, therightchesttubewasremoved.Thepericardialsacdrainwas removedonthe15thPO.Twodayslaterthepatientwasdismissed fromtheICUtotheTraumaWard,andwasdischargedthenextday. Hethenrecoveredwellandhisfollowupattheclinicswasﬁnished onthe28thdaypost-trauma(Fig.2).

3. Discussion

Accordingtomostauthors,pneumopericardiuminblunttrauma iscausedbyalveoliruptureduetosuddenriseinintrathoracic pres-sure,leadingtoairleaktothepericardium viapleural cavityin thepresence ofapleuropericardialtear,ifthevisceralpleurais disruptedcausingpneumothorax,orvialunginterstitium, track-ingalongtheperivascular planesofpulmonaryvesselsintothe mediastinum,neck,retroperitoneumandpericardium−whatis knownas“Macklineffect”.Anothermechanismwouldconsistin directappositionoftracheobronchialandpericardialtears[3,6,7]. Since our patient didnot present pneumothorax upon arrival, and tracheal and main bronchi lesions were excluded by ﬁber

Fig.2.PortableX-rayﬁlmobtainedintheEmergencyRoom,afterintubation.White arrowsindicatepericardiumstripeanditsunderlyingpneumopericardium.

bronchoscopy,hispneumopericardiumprobablyresultedfromthe Macklineffectorfromtheruptureofanon-primarybronchus.

Ifavalvemechanismoccurswithintheairpassagetothe peri-cardium,theincreasingpressuremayleadtocardiactamponade

[2].Adcockmeasuredpneumopericardiumhemodynamicimpact andfoundsigniﬁcantchangesinpulserate,arterialand venous pressurewhentheintrapericardialpressureexceeded145mmof water[8].Capizzietal.’sreviewof32casesofpneumopericardium following bluntinjury, 12 of which with tension pneumoperi-cardium,suggestsa correlationbetweenmechanicalventilation andtamponade−83%becameunstableunderpositive-pressure ventilation[3].

Tensionpneumopericardiumisacauseofhemodynamic insta-bility and the acute shock may be managed by pericardial decompression either by needle pericardiocentesis or percuta-neousdrainplacement.Theseemergencymaneuversshouldonly betemporary,andfollowedbytheplacementofasofttubulardrain intheoperatingroom,bysubxiphoidapproach,asinourcase,or byopenthoracotomy,orbyvideoassistedthoracoscopicwindow

[3,9].GouldandSchurrreportedtherecurrenceoftension pneu-mopericardiumonedayafterpercutaneousdrainage,whileunder mechanical ventilation,whattheyattributedtoapossibleplug, solvedafterforcefulaspirationfollowedbytheplacementofa tubu-lardrainundervideoassistedthoracoscopy[9].Ourpatientwas already extubatedwhen presentedtherelapseofa non-tension pneumopericardiumwhilstmaintainingafunctionaltubular peri-cardial drain,after disconnection of thesuction system.It was solved byconnecting it back for another48h. Thus, the main-tenanceof alow negativepressureinthedrainsystemmaybe necessaryinsomecases,particularlywhenapersistentairleakis present.

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Thiscasehasbroughtusexperienceinsuchararecondition. We now have a higher suspicion of pneumopericardium when assessing blunttrauma patients, considering it in the differen-tialdiagnosisofshock.We havealsorevisedandgroundedour management of this condition. In a similar scenario we would nowprobablydiagnoseitsoonerand,perhaps,wewould avoid hemodynamicdecompensationbyearlyaccomplishing pericardio-centesisand pericardialdrainage,beforeperformingan UDEor intubation.Weshouldalsobeawareofthepotentialrecurrence ofpneumopericardiumwhilemaintainingapericardialdrain,by itsobstructionorbythepresenceofapersistentairleak,evenif thepatientisnotunderpositive-pressureventilation−which rein-forcestheimportanceofintensivecaresupportuntiltheresolution ofthiscondition.

Conﬂictofinterest

Theauthorsdeclarenoconﬂictofinterest. Funding

Nosponsorinvolvement. Ethicalapproval

Noethicalapprovalisnecessaryforthiscasereport. Consent

Thepatienthasprovidedwrittenconsentforthepublicationof thiscasereport.

Authorcontribution

Antonio Fernando RolimMarques: author; Lizianne Hermo-genes Lopes, Marcela dos Santos Martins: co-authors; Cesar VanderleiCarmona,GustavoPereiraFraga,ElcioShiyoitiHirano: supervisors.

Guarantor

ElcioShiyoitiHirano. References

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