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Ann Thorac Surg 2001;72:1728-1730
© 2001 The Society of Thoracic Surgeons

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Case report

Tension pneumopericardium after blunt chest trauma

^a Department of Surgery, University of Wisconsin Hospital, Madison, Wisconsin, USA

Accepted for publication January 19, 2001.

* Address reprint requests to Dr Schurr, Department of Surgery, University of Wisconsin Hospital, 600 Highland Ave, Madison, WI 53792, USA
e-mail: schurr{at}surgery.wisc.edu

	Abstract

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We present a case of tension pneumopericardium in a patient involved in a motor vehicle crash. This patient was treated initially with a percutaneously placed drain and then definitively by a video assisted thoracoscopic pericardial window.

	Introduction

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T ension pneumopericardium is a very unusual cause of hemodynamic compromise in the blunt trauma patient. The patients are often severely injured and a high index of suspicion is required to make the diagnosis. Other more common causes of hypotension, such as hemorrhagic shock or tension pneumothorax, should be considered first. A previous review article disclosed 12 cases of symptomatic pneumopericardium.

A 31-year-old man was an unrestrained front-seat passenger in a high-speed, single motor vehicle crash. A prolonged extrication was required. The patient was agitated and complained of shortness of breath at a referring hospital. He was orotracheally intubated and bilateral tube thoracostomies were performed for bilateral pneumothoraces on initial chest radiograph. He was then transferred to our institution for further therapy. On arrival the patient was noted to be tachycardic to 160 beats per minute, hypertensive with a systolic blood pressure of 190 mm Hg, and anemic with a hematocrit of 22%. Diagnostic peritoneal lavage was negative. Given the initial chest radiographic findings (Fig 1), a computed tomographic examination of the chest was obtained (Fig 2), which demonstrated large bilateral hemopneumothoraces, large pneumopericardium, multiple rib fractures, bilateral clavicle fractures, and a sternal fracture. In addition, a left upper lung field staple line from a previous wedge resection for pulmonary bleb disease was noted. Bilateral chest tubes were in good position, but an air leak from the right-sided chest tube was large and nearly continuous. A small- to moderate-sized right-sided pneumothorax persisted despite placement of an additional chest tube.

View larger version (143K): [in this window] [in a new window]   Fig 1. Chest x-ray showing pneumopericardium.

View larger version (146K): [in this window] [in a new window]   Fig 2. Computed tomographic (CT) scan demonstrating pneumopericardium with the heart displayed posteriorly by air.

Recurrent hemodynamic compromise developed the next day and a near-arrest situation occurred. After this he responded to forceful aspiration of the pericardial drain. We concluded that the drain had become plugged and tension pneumopericardium had recurred. The patient was taken to the operating room after stabilization where he underwent a video assisted thoracoscopic pericardial window. The pericardium was filled with a significant amount of air and fibrinous debris. A 5 cm by 3 cm pericardial window was created. The two chest tubes on the right were replaced with two new tubes at the end of the procedure. This definitive therapy resulted in the resolution of his tension pneumopericardium and he was successfully weaned from the ventilator over the course of the next few days. Air leakage from the right chest subsided and all chest tubes were removed several days after extubation.

	Comment

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Tension pneumopericardium in any setting is unusual. Pneumopericardium is most often secondary to mechanical ventilation (infant > adult), related to invasive procedures (laparoscopy, endoscopy), or as a result of chest trauma (penetrating > blunt). In 1994, Levin and colleagues [1] found 263 reported cases of pneumopericardium. Hemodynamic compromise as a direct result of the pneumopericardium was noted in 105 of these patients (37%). Of those with tension physiology, 78 (74%) were newborn infants receiving mechanical ventilatory support, 15 (14%) were tension pyopneumopericardium, and 12 (11%) were posttraumatic tension pneumopericardium. In 1995, Capizzi and colleagues [2] reviewed 32 patients with pneumopericardium after blunt trauma. Of these 32 patients, 12 displayed clear evidence of tension pneumopericardium (37%). This is similar to the rate of tension physiology in the series of patients with pneumopericardium reported by Levin and colleagues [1].

Air gains access to the pericardial sac after blunt trauma in one of several ways. An abrupt increase in intrathoracic and intraalveolar pressure may lead to a disruption of the alveoli. If there is an associated tear in the visceral lung pleura, then air escapes into the thoracic cavity. A similar tear in the pericardium could allow air to escape into the pericardial sac. Pericardial tissue may act as a shutter valve, letting air into the sac but not back out into the thoracic cavity. It has also been suggested that some people may possess congenital pleural-pericardial connections [3]. Alternatively, air from ruptured alveoli may travel along peribronchial and perivascular sheaths to the lung hilum and gain access to the pericardial sac from there. Macklin [4] provided histologic evidence that pericardial tissue is not continuous at the reflection of parietal onto visceral pleura near the ostia of the pulmonary veins. He showed that air could track along these planes and into the pericardium. An additional possible mechanism for pneumopericardium is that a traumatic direct communication may be created between the tracheobronchial tree and the pericardial sac.

Many patients who ultimately developed tension physiology are mechanically ventilated before the development of tamponade. This occurred in 11 of 12 patients reviewed by Capizzi and colleagues [2]. This suggests that positive pressure ventilation may contribute to the tamponade effect. A high index of suspicion must be maintained in the patient with pneumopericardium that requires positive pressure ventilation.

Tension pneumopericardium should be initially treated with a fluid bolus and emergent pericardial decompression, either by a needle pericardiocentesis, percutaneous drain placement, or emergent open subxyphoid approach to the pericardium. We learned that percutaneous drains might not be sufficient to effectively manage the patient because the catheter may plug with pericardial sac debris. They should serve as a temporary access to the sac for immediate decompression. A permanent pericardial window performed in the operating suite should follow percutaneous drain placement. The window can be made either by an open subxyphoid approach, by open thoracotomy, or, as in our case, by video assisted thoracoscopic pericardial window. The thoracoscopic approach allows for concomitant examination of the lung, evacuation of retained hemothorax, and direct visualization of thoracostomy tube placement for lung reexpansion. Video assisted thoracoscopic pericardial window has the additional benefit of being able to decrease chest tube time in days for trauma patients with persistent air leaks [5].

	References

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1. Levin S., Maldonado I., Rehm C., Ross S., Weiss R. Cardiac tamponade without pericardial effusion after blunt chest trauma. Am Heart J 1996;131:198-200.[Medline]
2. Capizzi P.J., Martin M., Bannon M. Tension pneumopericardium following blunt injury. J Trauma 1995;39:775-780.[Medline]
3. Siplovich L., Bar-Ziv J., Karplus M., et al. The pericardial "window": a rare etiologic factor in neonatal pneumopericardium. J Pediatr 1979;94:975.[Medline]
4. Macklin C.C. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: clinical implications. Arch Intern Med 1939;64:913-926.[Abstract/Free Full Text]
5. Schermer C.R., Matteson B.D., Demarest G.B., Albrecht R.M., Davis V.H. A prospective evaluation of video-assisted thoracic surgery for persistent air leak due to trauma. Am J Surg 1999;177:480-484.[Medline]

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				M. Wu, X. He, and G. Yang Spontaneous tension hydropneumopericardium complicating serofibrinous pericarditis Eur J Cardiothorac Surg, March 1, 2006; 29(3): 422 - 424. [Abstract] [Full Text] [PDF]

				T. C. Roth and R. A. Schmid Pneumopericardium after blunt chest trauma: A sign of severe injury? J. Thorac. Cardiovasc. Surg., September 1, 2002; 124(3): 630 - 631. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gould, J. C. Articles by Schurr, M. A. Search for Related Content PubMed PubMed Citation Articles by Gould, J. C. Articles by Schurr, M. A. Related Collections Pericardium