Stable Traumatic Pneumopericardium – Operate or Hesitate?
Date First Published:
March 17, 2002
Last Updated:
May 6, 2003
Report by:
Mohammad Imran Zia, Spr in Emergency Medicine (Broomfield Hospital, Chelmsford)
Search checked by:
Paul Wallman, Broomfield Hospital, Chelmsford
Three-Part Question:
In [a haemodynamically stable patient following penetrating chest wall injury and fluid resuscitation with two litres of normal saline, does the presence of a pneumopericardium on Chest Xray] merit [urgent surgical intervention/exploration] to [reduce clinical course, adverse events, morbidity and mortality]
Clinical Scenario:
An 18-year-old male presents after having been stabbed with a 9inch screwdriver 1cm below the left nipple. On arrival he is tachycardic at 125 bpm with a blood pressure of 110/75. This settles with two litres of normal saline to a pulse rate of 85 bpm and a blood pressure of 129/82. He is fully alert. His chest X-ray reveals the presence of a pneumopericardium. He has no other injuries.
Search Strategy:
Medline 1966 to June 2001 using the OVID interface.
Search Details:
(exp fluid therapy/exp resuscitation/ or exp shock, haemorrhagic/ or exp shock, traumatic/ or fluid resuscitation". mp.) AND (exp cardiac tamponade/ or exp heart injuries/ or exp thoracic injuries/ or exp wounds, penetrating/ or exp wounds, stab/ or "penetrating chest trauma". mp.) AND (exp pneumopericardium/ or "pneumopericardium". mp) AND (exp "wounds and injuries"/ or "wounds. mp)
Outcome:
A literature search found 21 papers relating to this topic. Of these only 4 were found to be relevant. There was only one series which followed the results of 23 patients who were electively managed in the presence of a non tensioned pneumopericardium. There were also 3 isolated case reports relating to the management of a non-tension pneumopericardium.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Traumatic Pneumopericardium . Kumar V. 1973 Denmark | Isolated case | Case report | Survival | Isolated case | |
| Pneumoperitoneum Following Penetrating Chest Injuries. Demetriades D. Charalambides D. Pantaowitz D. Lakhoo M. 1990 S Africa | 20 stable cases aged 18-45 with confirmed pneumopericardium following penetrating chest trauma | Observational study | 19 cases survived | no operative intervention required | No control group used |
| 1 case tensioned with time | Required thoracotomy and survived | ||||
| Pneumopericardium after Thoracic Stab Wound. Pasic M. Hetzer R. 1999 Germany | Isolated case | Case report | Survival | Isolated case | |
| Pneumopericardium and Pneumoperitoneum after Penetrating Chest Injury. Rashid MA, Wikstrom T. Ortenwall P . 1999 Sweden | Isolated case | Case report | Survival | Stable patient but underwent surgery once diagnosis was made by CT |
Author Commentary:
Posttraumatic pneumopericardium is rare. However its presence is likely to be associated with an underlying cardiac abnormality. The studies published to date are mainly of how to manage a pneumopericardium once it has tensioned. All the cases described above, had relatively stable patients who nonetheless required stringent monitoring, with the availability of surgeons on hand to perform a thoracotomy had this proved necessary. These facilities may not be available to the majority of UK based district general hospitals.
Bottom Line:
A pneumopericardium in a haemodynamically stable individual may be managed conservatively. However stringent monitoring and the ready availability of a surgeon capable of performing a thoracotomy are required. For the district general hospital therefore consideration needs to be given to possibly transferring these patients to a more appropriate definitive care facility.
References:
- Kumar V.. Traumatic Pneumopericardium .
- Demetriades D. Charalambides D. Pantaowitz D. Lakhoo M.. Pneumoperitoneum Following Penetrating Chest Injuries.
- Pasic M. Hetzer R.. Pneumopericardium after Thoracic Stab Wound.
- Rashid MA, Wikstrom T. Ortenwall P .. Pneumopericardium and Pneumoperitoneum after Penetrating Chest Injury.