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Sciarretta JD, Noorbakhsh S, Joung Y, Bailey DW, Freedberg M, Nguyen J, Smith RN, Ayoung-Chee P, Davis MA, Benjamin ER, Todd SR. Pneumopericardium following severe thoracic trauma. Injury 2024; 55:111303. [PMID: 38218676 PMCID: PMC11023791 DOI: 10.1016/j.injury.2023.111303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/24/2023] [Accepted: 12/23/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Traumatic pneumopericardium (PPC) is a rare clinical entity associated with chest trauma, resulting from a pleuropericardial connection in the presence of a pneumothorax, interstitial air tracking along the pulmonary perivascular sheaths from ruptured alveoli to the pericardium, or direct trachea-bronchial-pericardial communication. Our objectives were to describe the modern management approach to PPC and to identify variables that could improve survival with severe thoracic injury. METHODS We conducted a retrospective study of the trauma registry between 2015 and 2022 at a Level I verified adult trauma center for all patients with PPC. Demographics, injury patterns, and treatment characteristics were compared between blunt and penetrating trauma. This study focused on the management strategies and the physiologic status regarding PPC and the development of tension physiology. The main outcome measure was operative versus nonoperative management. RESULTS Over a seven-year period, there were 46,389 trauma admissions, of which 488 patients had pneumomediastinum. Eighteen patients were identified with PPC at admission. Median age was 39.5 years (range, 18-77 years), predominantly male (n = 16, 89 %), Black (n = 12, 67 %), and the majority from blunt trauma (78 %). Half had subcutaneous emphysema on presentation while 39 % had recognizable pneumomediastinum on chest x-ray. Tube thoracostomy was the most common intervention in this cohort (89 %). Despite tube thoracostomy, tension PPC was observed in three patients, two mandating emergent pericardial windows for progression to tension physiology, and the remaining requiring reconstruction of a blunt tracheal disruption. The majority of PPC patients recovered with expectant management (83 %), and no deaths were directly related to PPC. CONCLUSIONS Traumatic PPC is a rare radiographic finding with the majority successfully managed conservatively in a monitored ICU setting. These patients often have severe thoracic injury with concomitant injuries requiring thoracostomy alone; however, emergent surgical intervention may be required when PPC progresses to tension physiology to improve overall survival.
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Affiliation(s)
- Jason D Sciarretta
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Soroosh Noorbakhsh
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US.
| | - Yoo Joung
- Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310, US
| | - Daniel W Bailey
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Mari Freedberg
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Jonathan Nguyen
- Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Randi N Smith
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Patricia Ayoung-Chee
- Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Millard A Davis
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - Elizabeth R Benjamin
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30307, US; Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
| | - S Rob Todd
- Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE Atlanta, GA 30303, US
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Pometlova J, Handlos P, Jecminkova R, Kitka M, Koscielnik P. Tension pneumopericardium in a polytrauma patient. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:91-94. [PMID: 34747414 DOI: 10.5507/bp.2021.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/19/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Tension pneumopericardium is a life-threatening condition, manifesting most commonly as hemodynamic instability caused by cardiac tamponade. Reduced cardiac output and blood pressure can lead to difficulties in the detection of arterial bleeding from associated injuries while the increased venous pressure can increase the rate of bleeding. CASE REPORT This is the case of a patient after a car accident, with bilateral serial fractures, bilateral pulmonary contusion, bilateral pneumothorax, emphysema of the neck and chest, pneumomediastinum and pneumopericardium, and other injuries. During treatment, the patient developed a gradually progressing hemodynamic instability, resulting in pulseless electrical activity. Further progression of the case is detailed in the paper. CONCLUSIONS Tension pneumopericardium is a rare complication of a high-energy blunt thoracic trauma that manifests through hemodynamic instability. Its treatment requires early diagnosis and immediate decompression of the pericardial cavity, which should, where possible, be performed even before putting the patient on mechanical ventilation as ventilation bears a high risk of worsening the pneumopericardium due to the increased air pressure in the lungs. During diagnosis and treatment of associated injuries, we must bear in mind that the hemodynamic changes caused by pneumopericardium can mask typical signs of such injuries.
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Affiliation(s)
- Jana Pometlova
- Institute of Emergency Medicine, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava-Vitkovice, Czech Republic.,Department of Trauma Surgery, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava-Poruba, Czech Republic
| | - Petr Handlos
- Institute of Forensic Medicine, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava-Poruba, Czech Republic
| | - Renata Jecminkova
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava-Vitkovice, Czech Republic.,Accident and Emergency Department, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava-Poruba, Czech Republic
| | - Miroslav Kitka
- Faculty of Medicine and Clinic of Trauma Surgery, Pavel Jozef Safarik University and Louis Pasteur University Hospital, Kosice, Slovak Republic
| | - Pavel Koscielnik
- Department of Radiology, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava-Poruba, Czech Republic
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Nasr A, Alsadery H, Osman A, Alblowi A, Bamalan O, Alshaikhi A, Alosaimi N, ElGhoneimy Y, Nabri M. Trauma-related pneumopericardium: A literature review. SAUDI JOURNAL FOR HEALTH SCIENCES 2023. [DOI: 10.4103/sjhs.sjhs_146_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
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4
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Adrover López PA, Diago Blanco DM, Santiago Rodríguez P, González Sanabria B, Rivera Berrios RJ. Complicated Iatrogenic Pneumopericardium in a Patient With Suspected Multiple Myeloma. Cureus 2022; 14:e24483. [PMID: 35651428 PMCID: PMC9132760 DOI: 10.7759/cureus.24483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/05/2022] Open
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5
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Anand R, Brooks Md Facs SE, Puckett Y, Richmond RE, Ronaghan CA. Pneumopericardium Resulting From Blunt Thoracic Trauma. Cureus 2020; 12:e11625. [PMID: 33376639 PMCID: PMC7755601 DOI: 10.7759/cureus.11625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Pneumopericardium is a rare clinical condition defined by the presence of air in the pericardial sac. While this initially does not pose much danger, the accumulation of a sufficient amount of air can convert the pneumopericardium to a tension pathology. This may present with the classic signs, symptoms, and lethal dangers of cardiac tamponade. As with cardiac tamponade, treatment involves decompression of the pericardial sac through pericardiocentesis. This may be followed by insertion of a pericardial tube for continued drainage. While cardiac tamponade is well recognized by its classic findings, the rarer pneumopericardium may be more easily missed. This is further complicated by the backdrop of concurrent traumatic injuries in which it typically presents, as well as the absence of the defining accumulated pericardial effusion. We present a case of a 38-year old male who developed pneumopericardium and worsening hemodynamic status as a complication to blunt trauma, a rare etiology for this condition. CT of the chest demonstrated air in the pericardium and a coexisting pneumothorax. A bedside chest tube was placed. Upon resolution of the pneumothorax, his hemodynamic status improved. Repeat bedside ultrasound demonstrated complete resolution of his pneumopericardium. This case emphasizes the importance of early recognition and diagnosis of this rare yet easily missed condition.
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Affiliation(s)
- Rohan Anand
- Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | | | - Yana Puckett
- Surgery, West Virginia University School of Medicine, Charleston, USA
| | - Robyn E Richmond
- Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
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Lonský V, Manďák J, Harrer J, Tuna M, Dvořák P, Dědek T, Dominik J. Posttraumatic Pneumopericardium: A Sign of Severe Injury or Radiodiagnostic Rarity? ACTA MEDICA (HRADEC KRÁLOVÉ) 2018. [DOI: 10.14712/18059694.2017.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We present three cases of pneumopericardium following blunt chest trauma injury. All three patients were victims of road traffic accidents. All had multiple associated injuries and pneumopericardium was found as the additional finding. Pneumopericardium was treated conservatively with thoracic drains placement and patients observation. Transesophageal echocardiography was used as a method of choice for exclusion of cardiac air tamponade. All three patients survived.
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Thoracic trauma in fatal falls from height - Traumatic pneumopericardium correlates with height of fall and severe injury. Forensic Sci Med Pathol 2018; 14:188-193. [PMID: 29725818 DOI: 10.1007/s12024-018-9977-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
Pneumopericardium (PPC) describes the collection of gas in the pericardial sac. In tension Pneumopericardium (tPPC), this collection of gas may lead to cardiac tamponade. PPC following blunt trauma is considered a rare finding, as reflected by the low number of case reports on the topic. We analyzed the prevalence and pathophysiology of PPC and the associated trauma in 44 cases of falls from height. We retrospectively analyzed postmortem CT data and autopsy reports of fatal falls in the period March 2014-2017. A valid estimation of the height of the fall and a documented impact on an even and hard surface were inclusion criteria. A total of 44 cases were included in the study. We identified PPC in 18 of the 44 cases, and it was associated with an increased height of the fall, alongside aortic, pericardial, and myocardial ruptures. All cases with PPC also presented with bilateral pneumothorax. Five cases presented with a "ballooning" pericardium, indicating tPPC. PPC is a common finding in cases of falls from great heights. Due to a significant correlation with height and thus impact severity, PPC may be used as a reconstructive element in medico-legal investigations. Association with trauma makes PPC a sign of severe thoracic injury in postmortem and clinical radiology.
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Maves RC, Tripp MS, Franzos T, Wallace SC, Drinkwine BJ, Villines TC. Pyogenic Pericarditis and Cardiac Tamponade Due to Streptococcus anginosus in a Combat Theater. Open Forum Infect Dis 2017; 4:ofw267. [PMID: 28470013 DOI: 10.1093/ofid/ofw267] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/20/2016] [Indexed: 11/13/2022] Open
Abstract
Streptococcus anginosus group pericarditis is rare. A 24-year-old male soldier presented for care at a military clinic in Afghanistan with shock and cardiac tamponade requiring emergent pericardial drainage and aeromedical evacuation. We review the patient's case, the need for serial pericardial drainage, and the available literature on this disorder.
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Affiliation(s)
- Ryan C Maves
- NATO Role 3 Multinational Medical Unit, Kandahar Airfield, Afghanistan.,Department of Pulmonary and Critical Care Medicine.,Division of Infectious Diseases, Department of Internal Medicine
| | - Michael S Tripp
- NATO Role 3 Multinational Medical Unit, Kandahar Airfield, Afghanistan.,Department of Pulmonary and Critical Care Medicine
| | - Tracy Franzos
- Kimbrough Ambulatory Care Center, Fort George G. Meade, Maryland
| | - Scott C Wallace
- NATO Role 3 Multinational Medical Unit, Kandahar Airfield, Afghanistan.,Departments of Anesthesiology
| | - Benjamin J Drinkwine
- NATO Role 3 Multinational Medical Unit, Kandahar Airfield, Afghanistan.,Radiology, Naval Medical Center, San Diego, California
| | - Todd C Villines
- Cardiology Service, Walter Reed National Military Medical Center, Bethesda, Maryland.,Craig Joint Theater Hospital, Bagram Airfield, Afghanistan
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9
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Castro Martins M, Bathe AP, Marr CM. Pneumopericardium associated with blunt thoracic trauma in an adult horse. EQUINE VET EDUC 2016. [DOI: 10.1111/eve.12625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - A. P. Bathe
- Rossdales Equine Hospital and Diagnostic Centre; Newmarket UK
| | - C. M. Marr
- Rossdales Equine Hospital and Diagnostic Centre; Newmarket UK
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10
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Air tamponade of the heart. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 13:150-3. [PMID: 27516791 PMCID: PMC4971273 DOI: 10.5114/kitp.2016.61052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 03/04/2016] [Indexed: 11/17/2022]
Abstract
Pneumopericardium is a rare disease defined as the presence of air or gas in the pericardial sac. Among the etiological factors, the following stand out: chest trauma, barotrauma, air-containing fistulas between the pericardium and the surrounding structures, secondary gas production by microorganisms growing in the pericardial sac, and iatrogenic factors. Until now, spontaneous pneumopericardium has been considered a harmless and temporary state, but a review of clinical cases indicates that the presence of air in the pericardium can lead to cardiac tamponade and life-threatening hemodynamic disturbances. We present the case of an 80-year-old patient with a chronic bronchopericardial fistula, who suffered from a cardiac arrest due to air tamponade of the heart.
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11
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Altoos R, Carr R, Chung J, Stern E, Nevrekar D. Selective Common and Uncommon Imaging Manifestations of Blunt Nonaortic Chest Trauma: When Time is of the Essence. Curr Probl Diagn Radiol 2015; 44:155-66. [DOI: 10.1067/j.cpradiol.2014.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 08/22/2014] [Accepted: 08/25/2014] [Indexed: 11/22/2022]
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12
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Visser F, Heine M, Levin AI, Coetzee AR. Pneumopericardium:two case reports and a review. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2008.10872544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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13
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Durando MM, Zarucco L, Schaer TP, Ross M, Reef VB. Pneumopericardium in a horse secondary to sternal bone marrow aspiration. EQUINE VET EDUC 2010. [DOI: 10.1111/j.2042-3292.2006.tb00419.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Kallel N, Beloeil H, Geffroy A, Albaladejo P, Marty J. [Post-traumatic tension pneumothorax and pneumopericardium in spontaneous ventilation]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2004; 23:364-6. [PMID: 15120782 DOI: 10.1016/j.annfar.2003.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2003] [Revised: 12/09/2003] [Accepted: 12/09/2003] [Indexed: 11/22/2022]
Abstract
The occurrence of tension pneumopericardium in patient in spontaneous ventilation after blunt trauma is rare. The diagnosis is difficult and it may remain unrecognized. The authors reported the case of a 50 year-old trauma patient with a tension pneumothorax associated with a pneumopericardium. The patient was not mechanically ventilated at any time. Pericardial relief was obtained by insertion of a chest tube.
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Affiliation(s)
- N Kallel
- Service d'anesthésie-réanimation, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92110 Clichy, France
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Einsiedel T, Liener U, Brinkmann A, Träger K, Liewald F, Perner S, Kinzl L, Gebhard F. [Fatal outcome after multiple trauma. The thoracic injury as the decisive factor]. Unfallchirurg 2003; 106:771-6. [PMID: 14631533 DOI: 10.1007/s00113-003-0646-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In patients suffering from multiple injury, chest trauma is often the main cause of fatality. A case report is given and the literature reviewed.A 49 years old motorcyclist hit a car frontally in a road accident. After primary stabilization and first clinical care, he was transferred to our trauma centre because of severe chest injury, suspected pericardial effusion and lesion of the thoracic aorta. Initial diagnostics (plain radiographs, CT scan of thorax, abdominal ultrasound, echocardiography) showed left-sided serial rib fractures, a fracture of the left scapula, a hematopneumothorax left-sided, bilateral lung contusion, a small pneumothorax of the right side, a minimal pericardial effusion and a small splenic hematoma. The patient was treated in the intensive care unit, and the situation was initially stable. After 12 h, respiration deteriorated and a bronchoscopy showed filling of the airways with mucous fluid. The CT scan showed a worsening of the pulmonary damage and increasing pericardial fluid compression. A pericardiotomy was carried out, but the situation remained unstable. The patient was treated with invasive ventilation (PEEP>10, FiO2>0,5). Sudden severe bleeding out of left lower lobe was managed by thoracotomy and lobectomy. The patient remained unstable and died 95 h after the accident. This case shows that the severity of chest trauma does not necessarily correlate with the initial clinical and radiological findings. Even with all diagnostic and therapeutic procedures, a fatal outcome could not be prevented. This demonstrates the role of chest injury as a major and unforeseeable cause of death in multiple trauma patients.
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Affiliation(s)
- T Einsiedel
- Abteilung für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum, Ulm.
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