Management of a pneumopericardium due to penetrating trauma

Pneumopericardium following severe thoracic trauma

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.

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.

Pneumopericardium with massive pericardial effusion in the setting of tuberculosis constrictive pericarditis: a rare case report

Constrictive pericarditis is an uncommon complication of acute pericarditis, mainly caused by non-idiopathic sources. Pneumopericardium is the presence of air in the pericardial sac resulting from various procedures and circumstances, including trauma, iatrogenic, non-iatrogenic and natural causes. Here, we report a 16-year-old girl who came to the cardiology outpatient complaining of weakness, abdominal distention and shortness of breath while lying down and exertion. An echocardiography evaluation revealed a thickened precordium and massive pericardial effusion. Pericardiocentesis was performed for diagnosis and treatment purposes. Despite the patient’s remaining symptomatic and having no improvement following the procedure, we decided to perform chest computed tomography, which revealed a thickened pericardium with pneumopericardium. Partial pericardiectomy was performed successfully, and the sample was sent to the pathology department, which confirmed tuberculous constrictive pericarditis. The patient’s symptoms improved, and she was discharged on postoperative Day 5 standing on her foot.

Surgical exploration for stable patients with penetrating cardiac box injuries: when and how? A cohort of 155 patients from Marseille area

BACKGROUND

The management of penetrating thoracic injuries in moribund or unstable patients is clearly described in contrast to that of stable patients, particularly for those with a cardiac box injury. This anatomic location suggests a potentially lethal cardiac injury and requires urgent therapeutic decision making. The present study aims at determining when surgical exploration is beneficial for stable patients presenting with penetrating cardiac box injuries (PCBI).

METHODS

This was a retrospective study of stable civilian patients with PCBI referred to level I trauma centers in the Marseille area between January 2009 and December 2019. Using post-hoc analysis of the management outcomes, patients whose surgery was considered therapeutic (group A) were compared with those surgery was considered non-therapeutic and with non-operated patients (group B).

RESULTS

A total of 155 patients with PCBI were included, with 88% (n = 137) of stab wound injuries (SW). Overall, surgical exploration was performed in 54% (n = 83), considered therapeutic in 71% (n = 59), and performed by video-assisted thoracoscopy (VATS) in 42% (n = 35) with a conversion rates of 14% (n = 5). Initial extended Fast Assessment with Sonography for Trauma (eFAST) revealed the presence of hemopericardium in 29% (n = 29) in group A vs 9.5% (n = 7) in group B, p = 0.010, and was associated with a negative predictive value of 93% regarding the presence of a cardiac injury. Chest tube flow was significantly higher in patients who required surgery, with a median (IQR) of 600.00 (350.00, 1200.00) mL vs. 300.0 (150.00, 400.00) mL (p = 0.001).

CONCLUSION

eFAST and chest tube flow are the cornerstones of the management of stable PCBI. Video-assisted thoracoscopy represents an interesting approach to check intra thoracic wounds while minimizing surgical morbidity.

LEVEL OF EVIDENCE

Level IV, prognostic study.

The Role of Ultrasound for Detecting Occult Penetrating Cardiac Wounds in Hemodynamically Stable Patients

BACKGROUND

There is evidence in favor of using the ultrasound as the primary screening tool in looking for an occult cardiac injury. We report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country.

METHODS

Data were collected prospectively. We included all consecutive patients 14 years and older who presented to the Emergency Trauma Unit with (1) penetrating injuries to the precordial area and (2) a systolic blood pressure ≥ 90 mmHg (hemodynamically stable). The main outcome measures were sensitivity, specificity, and positive and negative predictive values of ultrasound compared with those of the pericardial window, which was the standard test.

RESULTS

A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions.

CONCLUSION

We found that ultrasound was 79% sensitive and 92% specific for the diagnosis of occult penetrating cardiac wounds. However, it should be used with caution in patients with injuries to the cardiac zone and simultaneous left hemothorax.

Abdominal Stab Wounds with Tension Pneumopericardium Confirmed by Autopsy and Postmortem Computed Tomography

We present the first report of pneumopericardium observed by autopsy and on postmortem computed tomography (PMCT) images. The subject was a woman who died of self-inflicted stab wounds to the abdomen. The PMCT scan revealed air in the pericardial sac, a "flattened heart" sign, and retroperitoneal hemorrhage. Medicolegal autopsy revealed two abdominal stab wounds near the xiphoid process that had cut the apical pericardium and adjacent diaphragm and liver. Examination of the open thorax confirmed that the pericardial sac was distended with air. The wound extended to the abdominal aorta, causing retroperitoneal hemorrhage. PMCT images showed that the pneumopericardial volume was 133 mL. We believe that cardiac tamponade occurred resulting from the tension pneumopericardium; however, the effects were mitigated by hypovolemia secondary to the retroperitoneal hemorrhage as well as obstructive shock. Therefore, the cause of death appears to have been low-pressure cardiac tamponade.

[Pneumopericardium due to thorax compression : Overlooked resuscitation injury]

On postoperative day 15 after right upper lobectomy of a non-small cell lung cancer a 75-year-old patient developed bradycardia followed by asystole during hospitalization on the intensive care unit. After approximately 4 min of chest compressions, circulatory function was re-established but the patient suffered from tachycardia and required continuous vasopressor support. To exclude hypovolemia and assess contractility, transthoracic echocardiography (TTE) was conducted. During the TTE examination neither the intensive care physician nor the cardiologist on call could obtain usable images, which was explained by the lack of experience of both physicians with TTE. Both chest ultrasound and chest x-ray imaging did not reveal any signs of a pneumothorax. A small zone of increased transparency in the cardiac silhouette was not considered to be of pathological relevance. Slowly, the patient recovered. On the following day, a thoracic computed tomography (CT) scan showed an extensive pneumopericardium of the entire pericardium with a seam width of 3 cm. Because of the patient's clinical improvement, a decision for a conservative therapeutic approach was made and 24 h later the seam width was reduced to 2 cm and 9 days later it was no longer detectable. After a total stay of 24 days in the intensive care unit the patient was transferred to a long-term pulmonary care weaning facility. In retrospect, the pneumopericardium as a rare resuscitation injury was the cause for the poor TTE conditions and was overlooked due to a fixation error, because too much attention had been focused only on the detection of a pneumothorax.