Tension Pneumopericardium From Blunt Force Trauma: Resuscitating the Red Baron

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Trauma Center faced an atypical crash scenario where pilot wrecked his World War 1 replica Triplane.

A 60-year-old gentleman presented via ambulance to a Level Two Trauma Center following the crash of his World War 1 replica Triplane. Want to know why planes aren’t built like that anymore? They fly poorly. Aeronautical science was budding and things like airfoils, lift, drag, altitude performance and power plant reliability were just beginning to be studied and understood. Couple these flaws with the thin air of the mountain west and density altitude of a hot summer day and the odds are stacked against the pilot in the event of an emergency.

The aircraft struck the ground at a high rate of descent with significant frontal impact and deceleration trauma. Initial GCS was 5 and pre-hospital nasal-tracheal intubation was unsuccessful. On presentation, the pilot had multi-system trauma including subarachnoid hemorrhage, cervical and lumbar spinal fractures, and multiple orthopedic injuries including bilateral open Lisfranc fractures, solid organ contusions, as well as multiple rib fractures, bilateral pneumothoracies and pneumopericardium.

Vital signs included a blood pressure of 120/65, heart rate of 98, respiratory rate of 18 with bag valve ventilations, and pulse oxygenation of 94% on 100% FiO2. Patient required transfer to a higher level of care due to his multiple injuries. Prior to transfer bilateral chest tubes were placed, patient was intubated, and his multiple fractures splinted. On arrival to the Level One Trauma Center, patient abruptly developed worsening hemodynamic instability with blood pressure decreasing to 84/41, and heart rate climbing to 138.

 

 

 

 

 

 

 

Figure 1: Above
Axial view of chest CT showing the evolving tension pneumopericardium (Thick arrow) with air compressing the right ventricle. Slender arrow illustrating pneumothorax above lung with parenchymal contusion.

Figure 2: Below
Sagittal view of chest CT. Thick arrow demonstrates air in anterior pericardium compressing the right ventricle. Slender arrow illustrating anterior pneumothorax.

 

 

 

 

 

 

 

 


DIAGNOSIS: TENSION PNEUMOPERICARDIUM

While the physiology of tension pneumothorax is well known, with recognition and treatment composing a cornerstone of trauma resuscitation, tension pneumopericardium is much less common. In the most severe progression, life-threatening cardiac tamponade may occur.(1-9) Upon arrival to the Level One trauma center, the patient’s clinical presentation – hypotension, tachycardia, RV compression — was consistent with acute cardiac tamponade secondary to tension pneumopericardium. Patient underwent emergent left anterior thoracotomy showing a linear tear in the pericardium causing distraction of the pericardium on the left side, and compression of the right ventricular outflow tract and pulmonary artery. He underwent successful pericardiectomy with successful resolution of the vascular compromise.

Typically, pneumopericardium is believed to be benign and can be observed.(2) It can be caused by infection; iatrogenic injury; and blunt, penetrating or baro-trauma.(3) However, previous literature suggests up to 37% of patients with pneumopericardium due to blunt thoracic trauma may develop some degree of tension pneumopericardium.(3,4,5) As well, simple pneumopericardium may progress to tension pneumopericardium. As with tension pneumothorax, the development of tamponade physiology secondary to tension pneumopericardium is strongly associated with positive pressure ventilation.(3-9)

One theory is that air leaking form rupture alveoli tracks along the vascular sheath and spreads into the pericardial space.(6) While mortality of cardiac tamponade from tension pneumopericardium is high, early diagnosis and intervention with either open or percutaneous decompression can be life saving.(7-9)

Following a prolonged hospital course, multiple interventions for his extensive injuries and rehabilitation, the patient was fortunate to have a complete recovery and is back flying antique aircraft.

Jessica Gerczynski and Stephen Richey also contributed to this article.

REFERENCES

1. Polhill JL, Sing RF. Traumatic tension pneumopericardium. J Trauma 2009; 66:1261.

2. Fulda G, Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM, Cowley RA. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979-1989). J Trauma 1991;31(2):167–72 [discussion 72–3].

3. Levin S, Maldonado I, Rehm C, Ross S,Weiss RL. Cardiac tamponade without pericardial effusion after blunt chest trauma. Am Heart J 1996;131(1):198–200.
4. Capizzi PJ, MartinM, BannonMP. Tension pneumopericardium following blunt injury. J Trauma 1995;39(4):775–80.
5. Macgoey P, Schamm M, Degiannis E. Tension pneumopericardium: case report. Ulus Travma Acil Cerrahi Derg 2010;16(5):477–9.
6. Mansfield PB, Graham CB, Beckwith JB, Hall DG, Sauvage LR.  Pneumopericardium and pneumomediastinum in infants and children. J Pediatr Surg 1973; 8:691–9.
7. Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg 1984;37.
8. Nachi, S, et al.  “Simple pneumopericardium due to blunt trauma progressing to tension pneumopericardium during transport.” Am J Emerg Med. 2016;34: 933.e3-
9. Wei-Ting Lin, et al.  “Blunt Chest Trauma Associated with Tension Pneumopericardium . J Emerg Med. 50,4, 672-3, 2016.

ABOUT THE AUTHORS

Jonathan D Apfelbaum, MD, FACEP, is the Medical Director, Emergency Medical Services at Parker Adventist Hospital, Parker, CO.

William E. Robertson, DHSc is the Chairman, Emergency Care and Rescue Department, Weber State University, Ogden UT.

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