Thorax: first published as 10.1136/thx.32.1.91 on 1 February 1977. Downloaded from Thorax, 1977, 32, 91-97 Pneumopericardium and tension pneumopericardium after closed-chest injury S. WESTABY From Papworth Hospital, Cambridge Westaby, S. (1977). Thorax, 32, 91-97. Pneumopericardium and tension pneumopericardium after closed-chest injury. Three recent cases of pneumopericardium after closed-chest injury are described. The mechanism of pericardial inflation suspected in each was pleuropericardial laceration in the presence of an intrathoracic air leak. Deflation of the pericardium was achieved by underwater seal drainage of the right pleural cavity in the first patient, during thoracotomy for repair of tracheobronchial rupture-in the second, and by subxiphoid pericardiotomy in the last. Haemodynamic changes after escape of air from the pericardium of the second patient confirmed the existence of tension pneumopericardium and air tamponade. Pneumopericardium after a non-penetrating chest click. The right chest was resonant with decreased injury is rare. There are few previous reports of breath sounds. Precordial auscultation revealed a this lesion, and in the presence of additional in- loud splashing sound or 'bruit de moulin'. Chest jury its clinical importance remains poorly defined. radiographs demonstrated a large pneumopericar- This paper examines three recent cases in which dium and a 50% pneumothorax on the right, with operative deflation of the pericardium was per- no mediastinal shift. Needle aspiration of the http://thorax.bmj.com/ formed. In one case release of air resulted in pericardium was performed through the fourth marked haemodynamic changes leading to a left interspace and 40 ml of air with frothy blood diagnosis of tension pneumopericardium. was expelled in a pulsatile manner into the syringe. This did not alter the size of the pneu- Case 1 mopericardium radiologically. Insertion of an underwater seal drain into the right chest, how- On 21 August 1974 a 37-year-old construction ever, resulted in expansion of the right lung and worker fell from scaffolding, bouncing from pole deflation of the pericardium which was complete to pole and landing on a concrete floor 70 ft in 24 hours. on October 2, 2021 by guest. Protected copyright. (21 m) below. He sustained multiple injuries. Intermittent positive pressure ventilation with After resuscitation at the nearest hospital, where an initial inspired oxygen concentration of 50% a pneumopericardium was noted on the chest was required to maintain adequate oxygenation, radiograph (Fig. 1), the patient was transferred to and 31 units of blood were transfused during the the Birmingham Accident Hospital. first 36 hours. He was fully conscious but cyanosed with a To facilitate further management, a trache- raised jugular venous pressure, a blood pressure ostomy and internal fixation of the ankle fractures of 150/105 mmHg, and a tachycardia of 130 per were performed. His later course was complicated minute. His many skeletal injuries included bi- by profound hypoxia with chest radiographic lateral compound ankle fractures, fractures of the changes of bilateral patchy consolidation. Recur- pelvis, crush fractures of LI and L5 vertebrae, rent bouts of paroxysmal tachycardia were con- and subluxation at the Li/2 disc with cord tran- trolled with digoxin and practolol, and an ileus, section at this level. present on admission, resolved slowly over several Examination of the chest revealed bilateral dis- days. The pleural drain was removed on the sixth ruption of the first to fifth costochondral joints day, and after 26 days he was successfully weaned with paradoxical movement of the left second off the ventilator. Unfortunately, the paraplegia and third interspaces and an audible chondral showed no signs of recovery, and five weeks after 91 Thorax: first published as 10.1136/thx.32.1.91 on 1 February 1977. Downloaded from 92 S. Westaby http://thorax.bmj.com/ on October 2, 2021 by guest. Protected copyright. Fig. I Patient 1. (a) A posteroanterior chest radiograph showing the pneumopericardium shortly after admission to the Birmingham Accident Hospital. (b) Decubitus film showing shift of air within the pericardial sac, thus confirming its intrapericardial location. Thorax: first published as 10.1136/thx.32.1.91 on 1 February 1977. Downloaded from Pneumopericardium and tension pneurnopericardium after closed-chest injury 93 the accident he was transferred to the spinal in- over a 10-day period. Air was absent from the juries unit at Oswestry. pericardium 24 hours after operation. Case 2 Case 3 On 22 October 1975 a 23-year-old motorist sus- On 29 November 1975 an 18-year-old motorist tained chest and head injuries when his car sustained multiple injuries after collision with an collided with a tree. Not wearing a seat belt he articulated lorry. For an hour he remained trap- was thrown forward on to the steering wheel and ped and unconscious in the driver's seat and on through the windscreen. Remarkably, he walked arrival at the nearest hospital was unresponsive, one mile (16 km) to the nearest hospital where cyanosed, and profoundly hypotensive. Clinical he complained of chest pain and bloodstained assessment revealed facial fractures with loss of sputum. teeth and bleeding into the mouth and pharynx, Physical examination revealed lacerations of the bilateral fractured pubic rami, fractures of the face and scalp, tenderness over the lower third of left ulna and radius, and several rib fractures on the sternum, and gross surgical emphysema ex- the right side. Chest radiographs showed a small tending from the upper chest into his neck. He right pneumothorax with diffuse, patchy shadow- was cyanosed but normotensive and had a tachy- ing throughout the right lung field and a large cardia of 120 per minute. Chest radiographs pneumopericardium. He was resuscitated with (Fig. 2) showed a sternal fracture at the junction blood and dextran and ventilated artificially, and of the middle and lower thirds and an extensive after an initial improvement laparotomy was per- pneumopericardium and right pneumothorax. The formed for suspected intra-abdominal bleeding. right lung failed to expand after insertion of an This revealed a large intrapelvic haematoma re- underwater seal drain and there was a brisk air lated to the fractured pubic rami. leak from the right pleural cavity. He was there- After this there was an improvement in his con- fore transferred to the Regional Cardio-Thoracic scious state but considerable deterioration in res- Centre at Papworth Hospital. piratory function. Unfortunately, his lungs were On arrival his condition was found to have de- ventilated with 100% oxygen for four days, dur- teriorated; the blood pressure was 100/60 mmHg ing which time the chest radiograph (Fig. 3) http://thorax.bmj.com/ and pulse-rate 140 per minute. Surgical em- showed increasing patchy opacities in both lung physema had spread into the face. On auscul- fields, the development of bilateral pneumo- tation of the chest a loud splashing sound could thoraces, and a progressive increase in size of the be heard with muffling of heart sounds over pneumopericardium. He became restless, febrile, the precordium. There was a continued brisk air and increasingly hypoxic and developed surgical leak from the right pleural cavity. Bronchial emphysema of the chest and neck. At this stage rupture was diagnosed and bronchoscopy con- bilateral intercostal underwater seal drains were firmed a large tear at the origin of the right main inserted and he was transferred to the Cardio- bronchus, extending into the carina and lower Thoracic Surgical Unit at Papworth Hospital. on October 2, 2021 by guest. Protected copyright. trachea posteriorly. At thoracotomy extensive His condition on arrival was critical, a tension mediastinal emphysema was encountered and the pneumothorax having developed en route due to pericardium was seen to be bulging and tensely kinking of the right intercostal drain. He was inflated with air. Incision of the pericardial sac deeply cyanosed with tachycardia of 140 per resulted in expulsion of a large quantity of frothy, minute and a blood pressure of 200/110 mmHg. bloodstained fluid under considerable pressure, Precordial auscultation revealed a loud splashing with a subsequent rise in blood pressure from sound audible over the base of the heart, and the 110/70 to 130/90 mmHg. On inspection of the heart sounds were muffled. The chest radiograph deflated pericardial sac, a 3 mm tear on the pos- showed a ground-glass appearance over both lung terior wall adjacent to the bronchial tear was fields with a large pneumopericardium, medias- demonstrated. It was postulated that a valve tinal emphysema, and peribronchial interstitial mechanism had resulted in pericardial inflation emphysema. A clinical diagnosis of ruptured and air tamponade. After repair of both bronchial bronchus was made but repeated attempts at and pericardial tears the chest was closed with bronchoscopy were interrupted due to profound underwater seal drainage of the right pleural hypoxia and slowing of the heart rate. No bron- cavity. The patient continued to have a tachy- chial tear could be identified. In view of the cardia of 120 per minute which gradually settled balloon-like appearance of the pericardium on the Thorax: first published as 10.1136/thx.32.1.91 on 1 February 1977. Downloaded from 94 S. Westaby chest radiograph, and a central venous pressure of through which a brisk air leak persisted for 11 18 cm of water, elective drainage of the pericar- days. dium was performed via a subxiphoid approach. Further surgical intervention was deferred in On incision of the bulging pericardium, a large view of his poor overall condition. His course was amount of gas and yellow fluid was expelled under complicated by persistent severe hypoxia and de- pressure. An underwater seal drain was left in situ creasing pulmonary compliance requiring ventila- http://thorax.bmj.com/ on October 2, 2021 by guest. Protected copyright. Fig. 2 Patient 2.