Pneumomediastinum and pneumopericardium following blunt thoracic trauma: much ado about nothing?

Isolated Pneumopericardium: A Rare Manifestation of Penetrating Chest Trauma

Pneumopericardium (PPC) is a clinical entity defined by the presence of air in the pericardial sac. It occurs mainly in patients who sustain blunt or penetrating chest trauma and may coexist with pneumothorax, hemothorax, rib fractures, and pulmonary contusions. Although it is a strong indicator of cardiac injury and therefore requires immediate attention for possible surgical treatment, it still remains a commonly misdiagnosed condition in the trauma bay. Only a few cases of isolated PPC associated with penetrating chest trauma have been reported to date. We present the case of a 40-year-old man who was stabbed in the anterior chest, specifically in the left subxiphoid area and left forearm. Imaging, which included chest x-ray, chest computed tomography, and cardiac ultrasound, demonstrated the presence of rib fractures in addition to isolated PPC, with no pneumothorax or active bleeding. The patient was managed conservatively and actively monitored for three days and remained hemodynamically stable upon discharge. PPC is an uncommon clinical entity, suggestive of severe thoracic trauma. Clinical features may include chest discomfort and dyspnea, while asymptomatic patients have also been reported. Since it can be monitored by electrocardiograms and cardiac ultrasound, its presence is not an absolute indicator for surgical intervention, while the treatment plan should be based on the patient's clinical indications and symptoms.

Oesophageal Injury in Traumatic Pneumomediastinum: A Review of the Past 11 Years in an Upper Gastrointestinal Specialist Centre

Aims Pneumomediastinum is a known radiological finding after major thoracic trauma; however, its significance and required investigative workup are not standardized. Furthermore, there is little evidence to suggest that traumatic pneumomediastinum is indicative of oesophageal injury. Our study sets out to investigate the incidence of oesophageal injury for these patients at our centre, and the relevant investigative workup is required. Methods Medical records were retrieved from our trust (Major Trauma Centre: 2012 to present, Upper Gastro-Intestinal (UGI) Centre: 2009 to present) to include trauma patients with radiological pneumomediastinum admitted between 2010 and 2021. Demographics, mechanism of injury, length of stay, and other significant findings were collected retrospectively using the electronic patient record. Results The data search retrieved 37 patients with traumatic pneumomediastinum. One patient was excluded due to incomplete records. Road traffic collisions were the most common presentation (18 patients), followed by falls (13 patients), penetrating trauma (three patients), assault (two patients), and workplace injury (one patient). The median length of stay was six days, with two inpatient deaths. One patient had a confirmed tracheobronchial injury on initial imaging which was managed conservatively, while six other patients underwent further oral contrast CT for suspected oesophageal injury. No patients in our dataset had a confirmed oesophageal injury. Conclusion Oesophageal injury is rarely seen in traumatic pneumomediastinum and is usually secondary to other chest injuries causing an air leak into the mediastinum. Oral contrast CT is the recommended investigation to exclude oesophageal injury.

Risk factors for mediastinitis and mortality in pneumomediastinum

Introduction: Pneumomediastinum (PM) is a self-limiting disease with a good prognosis. Mediastinitis is a rare but potentially fatal complication of PM. Identification of risk factors for mediastinitis is essential for better management. Methods: This is a single-center, retrospective study conducted in a university hospital. Adult patients with PM between January 2016 and June 2020 were involved in the study. The data about age, gender, symptoms, signs, treatment, development of mediastinitis, hospital stay, and mortality were investigated. Results: In total, 79 patients with PM were analyzed. The most common symptom was dyspnea(58;73.4%) and the most common sign was subcutaneous emphysema (48;60.7%). Thirty(37.9%) of them were iatrogenic PM (IPM), while 22 (27.9%) were spontaneous PM (SPM) and27 (34.2%) were traumatic PM (TPM). Mediastinitis developed in 17 (12 from IPM, 4 from TPM,1 from SPM) patients, and 11 (58.8%) of these patients died. The incidence of mediastinitis in the IPM group was significantly higher than in the TPM and SPM group (respectively, P=0,03,P=0,01). There was no significant difference between the age, gender, symptoms, and signs of those with or without mediastinitis. Mortality was lower in TPM and SPM than IPM (respectively,P=0,05, P=0,03), and hematological malignancy was remarkably common in patients who died from mediastinitis in the TPM and SPM group. Conclusion: Mediastinitis and mortality were significantly higher in IPM, while hematological malignancy was remarkably prevalent in patients deceased from mediastinitis in TPM and SPM.

Neumomediastino en trauma contuso: ¿son siempre necesarios los estudios invasivos para descartar lesión aerodigestiva?

Introducción. La presencia de neumomediastino secundario a un trauma contuso es un hallazgo común, especialmente con el uso rutinario de la tomografía computarizada. Aunque en la mayoría de los casos es secundario a una causa benigna, la posibilidad de una lesión aerodigestiva subyacente ha llevado a que se recomiende el uso rutinario de estudios endoscópicos para descartarla. El propósito de este estudio fue determinar la incidencia de neumomediastino secundario a trauma contuso y de lesiones aerodigestivas asociadas y establecer la utilidad de la tomografía computarizada multidetector en el diagnóstico de las lesiones aerodigestivas. Métodos. Mediante tomografía computarizada multidetector se identificaron los pacientes con diagnóstico de neumomediastino secundario a un trauma contuso en un periodo de 4 años en un Centro de Trauma Nivel I. Resultados. Fueron incluidos en el estudio 41 pacientes con diagnóstico de neumomediastino secundario a un trauma contuso. Se documentaron en total tres lesiones aerodigestivas, dos lesiones traqueales y una esofágica. Dos de estas fueron sospechadas en tomografía computarizada multidetector y confirmadas mediante fibrobroncoscopia y endoscopia digestiva superior, respectivamente, y otra fue diagnosticada en cirugía. Conclusión. El uso rutinario de estudios endoscópicos en los pacientes con neumomediastino secundario a trauma contuso no está indicado cuando los hallazgos clínicos y tomográficos son poco sugestivos de lesión aerodigestiva.

[Pneumomediastinum in Severe COVID-19-disease: a Case Series of Eight Patients]

The most common cause of pneumomediastinum is trauma. However, in the context of COVID-19 pneumonia, this clinical picture is more often found in patients without underlying exogenous injury. Pathophysiologically, a cause analogous to the Macklin effect is suspected here, in which tears at the alveolar level lead to emphysema along the tracheobronchial tree with concentrating in the mediastinum. Here we present a case series of eight patients who were treated in our intensive care unit. In all patients, mediastinal emphysema could already be seen in the chest X-ray. Five patients also received a computed tomography scan of the thorax. Six patients had invasive ventilation. All patients received corticosteroids, anticoagulation and antibiotics. Pleural drainage was applied only in patients with an additional pneumothorax (n = 5). Bronchoscopy was performed only if there was a suspicion of iatrogenic injury to the tracheobronchial tree in relation to the appearance of the pneumomediastinum (n = 2). Three patients died during intensive care as part of the COVID-19 disease. A prognostic relationship between the occurrence of a pneumomediastinum and a fatal course of the disease is discussed.

Bilateral thoracic trauma; presentation and management, a case series

Introduction

Unilateral chest trauma has been perfectly described in the literature while bilateral chest trauma has never been specifically probed, the aim of this study is to highlight the specificities, presentations, the difference in the therapeutic algorithm and outcome of patients with bilateral thoracic trauma.

Patients and methods

A single center, prospective study was carried out in four years. The data were taken directly from the patients, patient's relatives and the medical records. All patients presenting with bilateral chest trauma, admitted to the hospital overnight, were included in this study. The patients were managed according to the Advanced Trauma Life Support (ATLS) protocol which consists of primary and secondary surveys. For those patients who diagnosed to have either haemo or pneumothorax or both, thoracostomy tube was inserted. Descriptive and analytical analyses were calculated.

Results

The study included 107 patients. Bilateral blunt trauma was found in 72 (67.3%) cases while bilateral penetrating trauma was found in 35 (32.7%) patients. The most common mechanism of trauma was road traffic accidents (RTA) accounting for 68 (63.6%) victims. Overall 30-day mortality was 14.9%. In blunt trauma, 3 or more rib fracture, pulmonary contusion, intubation, and intensive care unit admission were among the predictors of increased risk of mortality.

Conclusion

Bilateral thoracic trauma has comparable patterns of presentation, choices of investigation, strategies of management, predictors of the outcome, morbidity and mortality with unilateral chest trauma.

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Unilateral chest trauma has been perfectly described in the literature.

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While bilateral chest trauma has never been specifically probed in the literature.

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This study highlights the details of bilateral thoracic trauma.