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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 14-16

Traumatic tension pneumopericardium: A rare complication


Department of Critical Care Medicine, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India

Date of Web Publication15-Dec-2017

Correspondence Address:
Mohamed Hisham
Department of Critical Care Medicine, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jctt.jctt_12_16

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  Abstract 

A 36- year old male was admitted with shock following a road traffic accident. The patient had a low Glasgow Coma Scale score of 8/15 for which he was ventilated and intubated. Computed tomography scan showed pneumomediastinum and pneumopericardium along with left-sided hemopneumothorax. Hemopneumothorax was addressed with an intercostal drain. There was no further blood loss. Persisting hemodynamic compromise needing inotropic support prompted a diagnosis of tamponading effect of pneumopericardium. Pericardiocentesis was performed which resulted in immediate hemodynamic stability. The patient was discharged from intensive care unit after tracheostomy and had a complete recovery. Tension pneumopericardium is an extremely rare condition which can be fatal if left untreated. Prompt suspicion, diagnosis, and treatment of the condition in a hemodynamically unstable trauma patient can be lifesaving.

Keywords: Pericardiocentesis, pneumomediastinum, tension pneumopericardium, traumatic chest injury


How to cite this article:
Vivekananthan P, Sivakumar MN, Hisham M, Lakshmikanthcharan S. Traumatic tension pneumopericardium: A rare complication. J Cardiothorac Trauma 2017;2:14-6

How to cite this URL:
Vivekananthan P, Sivakumar MN, Hisham M, Lakshmikanthcharan S. Traumatic tension pneumopericardium: A rare complication. J Cardiothorac Trauma [serial online] 2017 [cited 2020 Nov 29];2:14-6. Available from: https://www.jctt.org/text.asp?2017/2/1/14/220842


  Introduction Top


Pneumopericardium is a rare medical entity, where there is air within the pericardial cavity. Tension pneumopericardium (TPP) is rarer but has a significant mortality rate of 56%.[1] Hence, this condition should be suspected in major trauma involving the chest, especially in situ ations where the hemodynamic instability is unexplained.


  Case Report Top


A 36-year-old male was involved in a high-velocity motor vehicle collision. He had no significant comorbidities. He received first aid and was shifted to a private hospital where he was intubated for low Glasgow Coma Scale score of 8/15. Subsequently, he was shifted to our tertiary care hospital for further management.

On initial assessment at our hospital, the patient was tachycardic, hypotensive, and he was supported with intravenous fluids and noradrenaline. He had multiple left-sided rib fractures with moderate hemopneumothorax for which an intercostal drain (ICD) was placed. He had multiple lacerations over the head, neck, anterior chest wall, and left elbow. In addition, he had subcutaneous emphysema over the chest wall and mandible fracture. Contrast-enhanced computed tomography (CT) of the thorax revealed surgical emphysema over the left chest and abdominal walls, multiple left-sided rib fractures, and left scapula fracture [Figure 1]. CT scan also revealed a significant pneumomediastinum and pneumopericardium that measured a maximum thickness of 2.5 cm. A left-sided small residual pneumothorax with ICD in situ was also noted. Persisting shock prompted us to seek for blood loss from other areas. Abdominal ultrasound was performed which was negative for neither organ injury nor hemoperitoneum.
Figure 1: Computed tomography scan of the chest demonstrating pneumomediastinum, pneumopericardium, and left-sided subcutaneous emphysema

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No major neuroparenchymal injury was evident on brain CT scan. Spinal injury was ruled out radiologically. Screening echocardiogram was not very informative as the window was poor due to subcutaneous emphysema.

Interventions

Aggressive fluid management was instituted. There was a sustained need for noradrenaline infusion. Subsequently, he had further hemodynamic compromise requiring additional adrenaline support. Mild drop in hemoglobin was addressed with one unit of packed red blood cells. Significant metabolic acidosis was present, which was corrected with sodium bicarbonate infusion. Jugular venous pulsation was raised. Chest radiograph showed adequate left lung expansion and pneumopericardium [Figure 2]. There was no increase in hemopneumothorax. The ICD in situ was thought to reduce the pneumothorax and in turn the pneumopericardium. We were aware that not all pneumopericardium needs draining unless tamponade effect is present. As the hemodynamic compromise persisted and that no other hemorrhagic causes were present, the shock was attributed to the possibility of pneumopericardium causing tamponade effect. Urgent cardiologist opinion was sought with a view to drain the TPP. Echocardiography by the cardiologist revealed compression of the right heart structures by the pneumopericardium, suggestive of tamponade effect. Emergency pericardiocentesis was performed through subcostal approach using 6F sheath and a pigtail catheter was inserted into the pericardial cavity [Figure 3]. Air and some blood-stained fluids were drained. Rapid improvement in the hemodynamic parameters was observed. Arterial lactate level was 35 mmol/L at initial assessment, subsequently deteriorated to 70 mmol/L during the hemodynamic instability, and improved to 47 mmol/L after the tamponade was addressed. The inotropes were gradually weaned and stopped after the pericardial drain was placed.
Figure 2: Chest radiograph showing adequate left lung expansion and pneumopericardium

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Figure 3: Chest radiograph showing pericardial drain in situ

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Recovery phase

In the subsequent days, there was minimal blood loss through the chest drain. Mild coagulopathy (international normalized ratio 1.5) was dealt with Vitamin K replacement. Bronchoscopy examination did not show any major airway injury which could have caused the pneumomediastinum. The pericardial drain did not drain any further. Repeat echocardiography did not show any residual. Hence, the sheath and pigtail catheter were removed after 2 days.

The patient had a good neurological recovery. Mandible fixation, suturing of lacerations, and orthopedic procedures were completed over the next 2 days. Epidural analgesia was instituted prior to extubation. The patient had to be re-intubated due to hypoxia from lung contusion on the 4th day. After reintubation, the patient underwent tracheostomy. Respiratory weaning was aided by second ICD placement to drain pleural effusion on the same side. After 9 days of intensive care, the patient was shifted to ward. Upon complete recovery, tracheostomy was de-cannulated in the ward and the patient was discharged out of hospital on day 32.


  Discussion Top


Pneumopericardium is a rare condition which is self-limiting and usually resolves spontaneously. However, TPP is life-threatening and requires immediate lifesaving intervention. Development of tamponade effect due to pneumopericardium is a poor prognostic sign with a very high mortality.

TPP is reported during intermittent positive pressure ventilation (IPPV), especially after traumatic injuries.[2] The mechanism of air entry into the pericardial cavity has been postulated by Macklin.[3] Air leak into mediastinal tissues from alveolar rupture raises the mediastinal pressure enough for the air to gain access into the pericardial sac through a traumatic pericardial tear. Such a potential air leak can be augmented by IPPV.[4],[5]

Cardiac tamponade effect due to pneumopericardium is a diagnosis based on clinical grounds with a high index of suspicion. The clinical picture of tamponade includes hypotension, tachycardia, tachypnea, raised jugular venous pressure, muffled heart sounds, pulsus paradoxus, and classical mill wheel murmur. In the reported patient, there were clinical features of cardiac tamponade. The echocardiographic evidences of cardiac tamponade were discussed by Cummings et al.[6] Severe chest trauma patients presenting with nonhemorrhagic shock should be explored to evaluate the causes for obstructive shock. In this case, a diagnosis of tamponade was suspected when shock persisted in the presence of pneumopericardium. In such circumstances, immediate lifesaving interventions such as pericardial decompression and pericardial drain placement should be instituted. Furthermore, in major trauma patients where mechanical ventilation is needed, augmentation of the pneumopericardium causing tamponade effect should be borne in mind.[7] Our experience with this case highlighted the rarity of the condition and enforced the need for a high index of clinical suspicion along with immediate lifesaving interventions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Adcock JD, Lyons RH, Barnwell JB. The circulatory effects produced in a patient with pneumopericardium by artificially varying the intrapericardial pressure. Am Heart J 1940;19:283-91.  Back to cited text no. 1
    
2.
Gould JC, Schurr MA. Tension pneumopericardium after blunt chest trauma. Ann Thorac Surg 2001;72:1728-30.  Back to cited text no. 2
[PUBMED]    
3.
Macklin C. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: Clinical implications. Arch Intern Med 1939;64:913-26.  Back to cited text no. 3
    
4.
Rolim Marques AF, Lopes LH, Martins Mdos S, Carmona CV, Fraga GP, Hirano ES. Tension pneumopericardium in blunt thoracic trauma. Int J Surg Case Rep 2016;24:188-90.  Back to cited text no. 4
[PUBMED]    
5.
Polhill JL, Sing RF. Traumatic tension pneumopericardium. J Trauma 2009;66:1261.  Back to cited text no. 5
[PUBMED]    
6.
Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg 1984;37:511-8.  Back to cited text no. 6
[PUBMED]    
7.
Haan JM, Scalea TM. Tension pneumopericardium: A case report and a review of the literature. Am Surg 2006;72:330-1.  Back to cited text no. 7
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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