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Pneumoperitoneum from Subcutaneous Emphysema After Blunt Chest Injury

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Pneumoperitoneum from Subcutaneous Emphysema After Blunt Chest Injury CASE REPORT Pneumoperitoneum from Subcutaneous Emphysema after Blunt Chest Injury Byung Hee Kang, M.D., Jonghwan Moon, M.D. Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea Correspondence to: Pneumothorax and pneumomediastinum can cause pneumoperitoneum, which does not Jonghwan Moon, M.D. require surgery. There are unverified theories pertaining to how air passes through the dia- Division of Trauma Surgery, phragm. We report a case of pneumoperitoneum caused by blunt chest injury that was Department of Surgery, Ajou successfully managed with conservative care. Although the pneumoperitoneum was caused University School of Medicine, by thoracic injury, we believe that the air did not pass through the diaphragm, but instead 164 WorldCup-ro, Yeongtong- came from the abdominal wall, as in subcutaneous emphysema. (J Acute Care Surg 2017;7: gu, Suwon 16499, Korea 30-33) Tel: +82-31-219-7764 Fax: +82-31-219-7781 Key Words: Pneumoperitoneum, Subcutaneous emphysema, Pneumothorax, Pneumomediastinum E-mail: [email protected] Received June 14, 2016, Revised September 24, 2016, Accepted September 28, 2016 Copyright © 2017 by Korean Society of Acute Care Surgery cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN 2288-5862(Print), ISSN 2288-9582(Online) https://doi.org/10.17479/jacs.2017.7.1.30 Introduction to the retroperitoneum and peritoneum. In massive subcutaneous emphysema, air could travel through Pneumoperitoneum following blunt force trauma usually indi- the tissue from the face to the buttocks and scrotum [5]. However, cates the need for an emergency laparotomy. However, 5~15% subcutaneous emphysema in the scalp was rarely reported. Here, of pneumoperitoneum cases do not require surgical management, we report subcutaneous emphysema in the scalp and pneumo- because the air comes from sources other than the hollow viscus peritoneum caused by a blunt chest injury. This case also suggests [1]. Pneumothorax or pneumomediastinum could lead to non- the existence of a new passageway via which air passes between surgical pneumoperitoneum, and several hypotheses have been the thorax and the abdomen exist. proposed on how the air passes from the thorax to the abdomen. Air could also directly pass through the diaphragm via dia- Case Report phragmatic defects [2]. Moreover, Lantsberg and Rosenzweig [3] suggested that communication between the thorax and abdominal A 46-year-old man, who had been beaten mainly in the chest cavity could exist through a weak site in the diaphragm (cor- region, visited a local clinic. Despite being intoxicated, he could responding to Bochdalek and Morgagni hernia). Romero and follow the doctor’s instructions. Initial oxygen saturation was 65% Trujillo [4] demonstrated that the air from the alveoli travels and dyspnea soon developed. After intubation, he was transferred through the perivascular connective tissue in the mediastinum to the trauma center. On arrival, his vital signs were as follows: 30 J Acute Care Surg Vol. 7 No. 1, April 2017 Byung Hee Kang and Jonghwan Moon: Pneumoperitoneum after Blunt Chest Injury blood pressure of 135/92 mm Hg, heart rate of 121 beats/min, emphysema. A small amount of hemothorax was also found on o oxygen saturation of 99%, and body temperature of 35.9 C. the chest radiograph pneumomediastinum was detected on a chest Crackling sensation of subcutaneous emphysema was palpated computed tomography (CT) (Fig. 1). An abdominal CT revealed from the head to the lower legs, and abrasions were seen on pneumoperitoneum in the liver dome and upper abdomen (Fig. both knees and on the right elbow. Some bruising was observed 2A). Air was dissected between the external and internal oblique on the chest and back; however, the abdomen wall was clear. muscles, and some air was present behind the rectus muscle. The abdomen was soft and presented with no muscle guarding. In the lower abdomen, much air was seen around both the psoas A chest radiograph showed pneumothorax, with multiple rib muscle and erecter spinae muscles. The region filled with air fractures on both sides of the chest and extensive subcutaneous was bigger than for the perivascular plane in the diaphragm level Fig. 1. Chest computed tomography revealed pneumothorax (white arrow), pneumomediastinum and rib fracture (black arrow) from blunt thoracic injury. Collapsed lung and subcutaneous emphysema Fig. 3. Brain computed tomography revealed subcutaneous emphy- were shown. sema in scalp and air in temporalis muscle (white arrows). Fig. 2. (A) Pnemoperitoneum (black arrows) and small retroperitoneal air in perivascular space (posterior black arrow) were present. Subcu- taneous emphysema was shown (white arrows). (B) Air existed behind rectus muscle (anterior black arrows) and around psoas muscle (posterior black arrows). Air dissected intermuscular layer (white arrows). www.jacs.or.kr 31 J Acute Care Surg Vol. 7, No. 1, Apr. 2017 Fig. 4. (A) Follow up abdominal computed tomography revealed improved pneumoperitoneum (black arrow) and subcutaneous emphysema (white arrows). (B) New pneumoperitoneum was appeared (black arrow) and subcutaneous emphysema was improved (white arrow). Air around psoas muscle was disappeared. (Fig. 2B). Brain CT revealed that subcutaneous emphysema was air, body temperature, leukocyte count, and physical examination. present throughout the scalp and that there was air inside the If a patient is stable and non-surgical causes of pneumothorax right temporalis muscle; however, pneumocephalus was not seen or pneumomediastinum exist, the patient can be observed. Marek (Fig. 3). A 28-Fr chest tube was inserted into both sides, and et al.[7] demonstrated that pneumoperitoneum in CT scan was the patient was admitted to the intensive care unit (ICU). In not sufficient for laparotomy, but additional findings were nece- the ICU, he was stable and extubation was performed the ssary (e.g., free fluid, bowel wall thickening, bowel wall discon- following day. Two days after admission, a follow-up CT was tinuity, solid organ injury, mesenteric injury, diaphragmatic rup- performed, which revealed that the extent of subcutaneous ture). However, both algorithms emphasized the importance of emphysema and pneumoperitoneum had decreased (Fig. 4A). physical examination or a patient’s complaint. Indeed, in patients However, the pneumoperitoneum was newly developed in the with multiple trauma, vital signs or laboratory findings can easily lower abdomen (Fig. 4B). A brain CT revealed that subcutaneous deteriorate. Even a physical examination or complaint could be emphysema had also improved, and air had disappeared from inaccurate due to a distracting injury. Therefore, examination inside the temporalis muscle. Due to a lack of signs of peritonitis, should be followed up frequently and the physician should always the patient was started on a diet of soft foods and was moved consider an emergency laparotomy if it is suspected to be to the general ward. He was discharged nine days following necessary. In this case, the patient was admitted to the ICU and admission. was monitored by an intensivist throughout the day. Since he was stable and did not develop any other symptoms, we continued Discussion conservative care, even though a follow-up CT scan revealed that pneumoperitoneum had newly developed. We demonstrated that extensive subcutaneous emphysema and There were several mechanisms proposed for the development pneumoperitoneum caused by traumatic pneumothorax were of pneumoperitoneum from thoracic injury; however, these were cured successfully by conservative care methods. only focused on diaphragm [2-4]. In our case, air was dissected Laparotomy is a difficult choice when pneumoperitoneum and in the inter-muscular space in the abdominal wall and erecter pneumothorax exist after blunt injury. Hoover et al.[6] suggested spinae muscle, and air was shown behind the rectus muscle and an algorithm that was composed of chest radiograph for free around the psoas muscle. We proposed that the newly developed 32 www.jacs.or.kr Byung Hee Kang and Jonghwan Moon: Pneumoperitoneum after Blunt Chest Injury pneumoperitoneum originated from these spaces for several was not suspected. However, extensive subcutaneous emphysema reasons. First, the location of the pneumoperitoneum was near was found, and in such a condition, the high pressure of air the rectus muscle, where air had been detected previously. Second, could possibly tear the peritoneum. Therefore, air may not pass on abdominal CT, pneumoperitoneum was associated with the the peritoneum in classic subcutaneous emphysema. air located between the extraperitoneal space and the abdominal Air from thoracic injury could directly pass through the wall. Third, the patient was bed-ridden in the ICU; hence, the abdominal wall and cause pneumoperitoneum. Surgical interven- pneumoperitoneum could not translocate and the air over the tion is not needed in such a case. liver could not travel to the lower abdomen. Fourth, there was much more air in the lower abdominal wall and psoas muscle Conflicts of Interest than perivascular space at the diaphragmatic level. Therefore, air passed over the diaphragm and penetrated the intraperitoneum No potential conflict of interest relevant to this article
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