Clinics and Practice 2011; volume 1:e70

Pneumomediastinum and utes. En route, they had noticed that he was barely conscious, able to follow a few com- Correspondence: Stalin Viswanathan, bilateral pneumothorax mands and had shallow breathing. He was Department of internal medicine, Pondicherry following near drowning nasally intubated and brought to our institu- Institute of Medical Sciences, Kalapet, in shallow water tion about three hours later. On examination Pondicherry-605014, India. he had tachycardia 130/min, tachypnea 26/min Tel: 91.0413.3051111. E-mail: [email protected] Santhiya Govindaraj, Stalin Viswanathan and systolic blood pressure of 60 mm Hg. Bilateral air entry was reduced albeit with Pondicherry Institute of Medical Sciences, Key words: near drowning; pneumomediastinum; crackles basally, and he was awake, obeying acute respiratory distress syndrome; complica- Kalapet, Pondicherry, India commands with no focal neurological deficits. tions. His investigations were: hemoglobin 21.4 g/dL, haematocrit 60, urea 10.7 mmol/L, creati- Contributions: SG, manuscript writing and final nine 176.6 µmol/L, potassium 2.6 mEq/L, meta- approval; SV, manuscript conceiving, literature searching, reviewing and final approval. Abstract bolic acidosis, sinus tachycardia on electrocar- diogram, and bilateral lung infiltrates, bilateral Conflict of interest: the authors report no con- We report pneumomediastinum, bilateral pneumothorax and pneumomediastinum on flicts of interest. pneumothorax and acute respiratory distress chest radiography (Figure 1A). His central syndrome in a victim of near drowning who venous pressure was 6cm of saline following Received for publication: 27 August 2011. was intoxicated and did not have thoracic or which fluids and inotropes (dopamine and dobu- Accepted for publication: 19 September 2011. neck trauma. Chest radiograph revealed the tamine) were administered. The patient also above findings, later confirmed by computed had upper gastrointestinal (GI) bleeding follow- This work is licensed under a Creative Commons tomography. He was in shock and also had gas- Attribution NonCommercial 3.0 License (CC BY- ing which he was transfused two units of red NC 3.0). trointestinal (GI) bleeding and renal dysfunc- blood cells (RBCs). On the second day subcuta- tion. With adequate resuscitative measures neous emphysema over neck was noticed and a ©Copyright S. Govindaraj and S. Viswanathan, 2011 including fluids, blood transfusions, inter- computed tomography of the chest was per- Licensee PAGEPress, Italy costal tube drainage and mechanical ventila- formed to rule out chest trauma. Echo - Clinics and Practice 2011; 1:e70 tion he made a complete recovery. Good prog- cardiography was normal; a left sided intercostal doi:10.4081/cp.2011.e70 nostic indicators in near drowning patients chest tube was placed and removed on day 4 of include higher Glasgow Coma Scale, short sub- admission. Inotropes were tapered and stopped mersion time and quick resuscitative meas- on the third day. His renal function improved patient’s sodium was normal. Hypokalemia is ures even in the presence of serious cardiores- with fluid management and he was discharged seen in 50% of fatal drowning incidents.5 piratory or hemodynamic compromise. on day 10 with the presence of a small pneu- Hemoconcentration is generally seen in sea mothorax on the right side. On a follow up visit water drowning,4 but our patient who drowned two weeks later his chest x-ray (CXR) was nor- in a pond presented with elevated hematocrit mal and he remained symptom free. and low central venous pressure (CVP). His Introduction upper GI bleeding probably contributed

Unintentional drowning accounts for about A C 8% of injuries related deaths. A majority of Discussion these drowning related deaths occur in devel- oping and under developed countries.1 About Drowning is suffocation arising from sub- 86000 deaths related to drowning had been mersion in a liquid medium, generally water reported in India (in 2000), with a mortality and near drowning is at least temporary sur- rate of 8.5%.1 The lack of sufficient education vival following drowning that enables a patient in drowning prevention and resuscitation has to obtain health care.2 Near drowning is much B resulted in thousands of unnecessary deaths. more common than drowning. Most such inci- Here we report a case of secondary pneumo- dents are under-reported, although up to half a mediastinum, bilateral pneumothorax and million deaths occur worldwide due to drown- acute respiratory distress syndrome (ARDS) in ing.3 Ninety percent of near drowning inci- a male with near drowning that recovered with dents are wet drowning wherein small to large conservative therapy. amounts of fluid are aspirated into the lungs along with temporary laryngospasm.2 Wet drowning with fresh or sea water generally dis- rupts surfactant lining and hence alveolar col- Case Report lapse, adult respiratory distress syndrome, hypoxemia and cerebral hypoxia occur. Drug This 24-year-old college student was brought intoxications, arrhythmias, depression, epilep- Figure 1. A) Chest x-ray (CXR) at admis- to the emergency with history of drowning in a sy, head injuries and accidental falls are com- sion showing bilateral pneumothorax, fresh water pond. He had been waist-deep in mon causes of near drowning.2,4 About 20-25% pneumomediastinum; B) computed tomography (CT) thorax revealing pneu- the pond drinking alcohol, while his friends of young adult (especially males) deaths asso- mothorax, pneumomediastinum, crazy who were swimming had been unaware when ciated with water recreation activities are seen pavement pattern of collapsed lung seg- he had slipped into the water. He was immedi- with alcohol use4 as in our patient. Serum ments; C) CXR with bilateral pneumotho- ately rescued when his absence was noted and sodium may be altered depending on whether rax and pneumomediastinum reduced taken to a nearby hospital within thirty min- fresh or seawater was aspirated, but our markedly following chest tube insertion.

[Clinics and Practice 2011; 1:e70] [page 145] Case Report towards his contracted intravascular volume ature, depth of water and nature of the water.10 adults within the emergency department. and shock. Computed tomography (CT) find- Complications arising from submersion Austral Emerg Nurs J 2006;9:3-9. ings of near drowning including pneumomedi- include aspiration, chest trauma, arrhythmias, 3. Papa L, Hoelle R, Idris A. Systematic astinum, crazy pavement appearance, ground- pulmonary edema, dehydration, dyselec- review of definitions for drowning inci- glassing as reported in a study were also seen trolytemia, renal failure and rhabdomyolysis.4 dents. Resuscitation 2005;65:255-64. in our patient6 (Figure 1B). CT chest revealed no trauma, while 4. Moon RE, Long RJ. Drowning and near- Pneumomediastinum is presence of free air hypokalemia, renal failure and pulmonary drowning. Emerg Med (Fremantle) in the mediastinum, that originates from the edema were seen in our patient. Good prognos- 2002;14:377-86. alveolar space or airways.7 Pneumome - tic indicators in the emergency include 5. Oehmichen M, Hennig R, Meissner C. diastinum had been reported initially in 1819 GCS>5/15, short submersion time and sponta- Near-drowning and clinical laboratory 2 and has been described in the setting of labor neous respiration and cardiac activity all of changes. Leg Med (Tokyo) 2008;10:1-5. and child birth, reactive airway diseases, sur- which were observed in our patient. 6. Kim KI, Lee KN, Tomiyama N, et al. Near In conclusion, we report a case of pneumo- geries to the neck and tonsils, blunt chest trau- drowning: thin-section CT findings in six 8,9 mediastinum in near drowning that followed ma and illicit drug inhalation. CT did not patients. J Comput Assist Tomogr 2000;24: reveal trauma to the neck due to nasal intuba- slipping into the water in an intoxicated state 562-6. tion. Pneumomediastinum and pneumothorax which has not been previously reported. 7. Shah S, Thomas S, Gibb E. Pneumo - are the common manifestations of pulmonary Presence of shock, upper GI bleeding, pneumo- mediastinum after shallow water diving. J barotrauma. Shallow diving has been reported mediastinum, pneumothorax were not poor Emerg Med 2009;36:76-7. once, to cause pneumomediastinum.7 Apart prognostic indicators when the sensorium was 8. Koullias GJ, Korkolis DP, Wang XJ, from barotrauma, coughing and breath holding normal and could be treated conservatively. during the drowning process that possibly Hammond GL. Current assessment and occurred in our patient, can also lead to pneu- management of spontaneous pneumome- momediastinum due to elevation of intraalveo- diastinum: experience in 24 adult lar pressures and subsequent alveolar rupture. References patients. Eur J Cardiothorac Surg 2004;25: Most cases of pneumomediastinum can be 852-5. managed conservatively. Due to presence of 1. Drowning. In: World Health Organization 9. Marioni G, De Filippis C, Tregnaghi A, et pneumothorax and haemodynamic instability, Injuries & Violence Prevention- Non- al. Cervical emphysema and pneumomedi- a left sided chest tube drain was placed (Figure Communicable Diseases and Mental astinum after tonsillectomy: it can happen. 1C). The right sided pneumothorax improved Health World Health Organization:1-8. Otolaryngol Head Neck Surg 2003;128:298- on its own. Factors governing prognosis in http://www.who.int/violence_injury_pre- 300. drowning incidents include time submerged, vention/ Accesssed: 14 June 2011. 10. Harries M. Near drowning. BMJ 2003;327: timely and quality resuscitation, water temper- 2. Meacher S. Managing near drowning of 1336-8.

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