Commentary :
Pneumopericardium is presence of air within the
pericardial space. It is rare complication of blunt or penetrating chest trauma
and may also occur iatrogenically. A case report of pneumopericarium caused by
blunt chest trauma, condition was diagnosed by chest CT (Computed Tomography) scan;
patient was vitally stable and managed conservatively with spontaneous
resolution of pneumopericardium 10 days after admission. A
case report published on 19th November 2019 in Cirugía Cardiovascular
journal about a thirty seven years old male patient with pneumopericardium
following a blunt trauma. On arrival of the patient, he was vitally stable,
clinical and radiological survey was done, Plain Computed Tomography
(CT) chest showed pneumopericardium without evidence of pneumothorax or
pneumomediastinum, Abdominal Ultrasound noticed mild to moderate
intra-peritoneal collection and CT abdomen with intra venous contrast was done
showing urinary bladder injury. Echocardiogram was
done to assess cardiac ejection fraction, cardiac chamber dimensions, presence
of pericardial effusion, abnormal wall motion and echocardiography signs of
tamponade. As the patient was fully conscious and with stable vital signs, he
was diagnosed as Simple Pneumopericardium and he was managed by close
monitoring of vital signs throughout admission, bilateral chest tube
thoracostomy were done as a prophylactic maneuver and regular follow up of the
patient by clinical and radiological assessment with erect chest X-ray to
assess resolution of the pneumopericardium. Ten
days after the accident, complete resolution of the pneumopericardium
developed and the patient was discharged. Pneumopericardium is a very rare
condition that may arise spontaneously or secondary to blunt with high
mortality rate 37%, as it can complicate into tension pneumopericardium causing
cardiac tamponade and threatening life of the patient. Tension
pneumopericardium mandates decompression by percutaneous or open drainage. The
presence of extra luminal air is a frequent complication in cases of blunt thoracic trauma,
because the differing electrophysiological behaviour of air can cause the ECG
(Electrocardiogram) to change frequently. The incidence of pneumothorax in this
population is approximately 40%, while that of pneumomediastinum may be as high
as 10%. Pneumopericardium, however, is rare and, to the best of the authors
knowledge, no incidence rates have been recorded. Neither have any clinical
trials been conducted on trauma patients in which this pathological entity is
described. This report describes a rare case of pneumopericardium after blunt
chest trauma. The condition was rapidly diagnosed with early CT scanning and
clinical assessment and distinguished from other possible differential
diagnoses such as myocardial contusion and myocardial infarction. That
was extremely vital because of the possible development of tension
pneumopericardium which is a life threatening condition that mandates rapid pericardial evacuation
either percutaneous or through pericardial window. In this case, a likely
differential diagnosis was myocardial contusion, which has a broad variety of
presenting symptoms, the most frequent being precordial pain not relieved by
analgesia. In addition to ECG changes, other findings include dyspnea,
pericardial friction rub and an elevated central venous pressure. This
complex of symptoms may mimic those of acute coronary syndrome,
although symptoms may also be completely absent. Myocardial contusion can be
diagnosed using echocardiography, as this imaging modality visualizes the
actual contusion as well as changes in cardiac chamber size, wall motion
abnormalities and the presence of cardiac tamponade. Echocardiography
was performed on this patient after pneumopericardium had been diagnosed and
cardiac contusion was excluded. Although cardiac contusion might easily have
coexisted, none of the aforementioned abnormalities were seen. Acute coronary
syndrome was unlikely to occur in this patient because he was young with no
history of chronic
illnesses and had no predisposing medical history, such as angina. However,
even in young people traumatic
myocardial infarctions have been reported that can result from acute
thrombotic coronary occlusion, intimal tears and vessel rupture.
Unfortunately, Cardiac enzyme profile with serial measurements of CK and
accessory MB-fraction in addition to the level of troponins, which has been
shown to be more useful in detecting myocardial injury than CK and CKMB (Creatine
Kinase-MB fraction) over the past decade, were not measured. Nonetheless, it was concluded
that significant myocardial
contusion or infarction was highly unlikely. According to most authors,
pneumopericardium in blunt trauma is caused by alveoli rupture due to sudden
rise in intrathoracic pressure, leading to air leak to the pericardium via
pleural cavity in the presence of a pleuropericardial tear, if the visceral
pleura is disrupted causing pneumothorax, or via lung interstitium, tracking
along the perivascular planes of pulmonary vessels into the mediastinum, neck,
retroperitoneum and pericardium what is known as Macklin effect. Another mechanism would consist
in direct apposition of tracheobronchial and pericardial tears. Since our
patient did not present pneumothorax upon arrival, his pneumopericardium
probably resulted from the Macklin effect or from
the rupture of a non-primary bronchus. However, a flexible bronchoscope could
be done for definitive exclusion of tracheal or main bronchial injury. Tracheobronchial injury
is considered serious and fatal complication of thoracic blunt trauma that is,
unfortunately, easily missed. Tension Pneumopericardium develops when a valve
mechanism occurs within the air passage to the pericardium leading to an
increase in the intra cardiac pressure compressing the great vessels causing
impairment of the venous return and cardiac output leading to hemodynamic
instability and cardiac tamponade that requires urgent evacuation of the
pericardium percutaneous or through pericardial window. As mentioned by this report,
clinical and radiological assessment of the patient showed that the patient was
vitally stable, also the close clinical monitoring and radiological assessment
throughout the admission did not report any instability in vital signs, so the
patient was in Simple Pneumopericarium and did not require invasive maneuver
for drainage of the pneumopericardium either percuateneous or pericardial
window. Although, bilateral chest tube
thoracostomy were done as a prophylactic maneuver to prevent development of
tension pneumothorax. This plan of conservative management of the patient was
supported by the stable condition of the patient plus the close monitoring
throughout the admission duration, this conservative plan was better than other
plans that suggest prophylactic
pericardial decompression of simple pneumopericardium. Both percutaneous and open
drainage of the pericardial sac are invasive procedures with significant risk
of morbidity and mortality. They should be reserved for patients with evidence
of hemodynamic instability and cardiac tamponade Tension Pneumopericarium. However, the bilateral chest tube
thoracostomy were of limited value as the patient was closely monitored and vitally
stable with regular follow up with erect chest X-rays, any deterioration in the
patient clinical status by clinical or radiological assessment could be easily
detected and the proper management could be done then. Ten days after the
accident a CT chest was done to the patient showing total resolve of the
pneumopericardium No other mentioned data about following up the patient either
inpatient or after discharge from the hospital. While dealing with Pneumopericardium
you should be aware of the potential recurrence of pneumopericardium even if it
is totally resolved or successfully drained as the pericardial drain
could be obstructed or the presence of a persistent air leak, even if the
patient is not under positive-pressure ventilation which reinforces the
importance of intensive care support until the resolution of this condition. To summarize we are dealing here
with a report of a rare case of simple pneumopericardium after blunt chest
trauma, the case was rapidly diagnosed after exclusion of other possible
diagnoses, although serum
cardiac enzymes (CK and accessory MB-fraction) and the level of troponin
were not measured. Conservative plan of management
was successful with no need of prophylactic drainage of the pericardial sac.
Bilateral chest tube thoracostomy still of low value especially when the
patient was closely monitored and serial chest X-rays were done. No available
data of following up the patient or definitive exclusion of recurrence of
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Cardiology (2004) Eur Heart J 25: 587-610. Amr Abd-El Moneim Shalaby, Department of
Cardiothoracic surgery, Suez Canal University, Egypt, E-mail: dramrshalabycts@gmail.com Shalaby AAM. Pneumopericardium
following blunt trauma (2019) Clinical Cardiol
Cardiovascular Med 3: 40-41. Pneumopericardium, Trauma, Electrocardiogram, Spontaneously.Commentary letter: Pneumopericardium Following Blunt Trauma
Amr Abd-El Moneim Shalaby
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