Management of Traumatic Tension Pneumopericardium

Introduction: Tension pneumopericardium (tPPC) is a rare diagnosis - a collection of air within the pericardial sac causing cardiac tamponade and subsequent circulatory collapse. TPPC is a life-threatening and important diagnosis to consider during initial evaluation of a blunt thoracic trauma. PPC can be diagnosed on chest x-ray but is often not present or appreciated until after CT scan. Despite emergent treatment with pericardiocentesis or pericardial window, PPC remains a negative predictor for mortality.


Description: A 30 year old male motorcyclist presented as a Level one with a right tension pneumothorax. He underwent rapid sequence intubation and placement of a right chest tube. Initial FAST was negative but upon CT imaging, PPC/pneumomediastinum and a left hemo/pneumothorax were identified, and a left chest tube was placed. Due to refractory hypotension, CT surgery was STAT consulted and patient was taken emergently to the operating room for pericardial window and drain placement. Post operatively, his hemodynamics stabilized and pericardial drain was removed on postop day 1. Postop days 7 to 10, the chest tubes were consecutively placed to water seal and removed. The patient was extubated to Optiflow on hospital day 12 and discharged to rehab on hospital day 22.


Discussion: Although our patient’s right pneumothorax was addressed expeditiously, his course was complicated by development of tPPC. Despite a documented mortality rate of 58% for tPPC (Cummings et al), our patient was treated with a pericardial window and drain, recovered, and was eventually discharged. Nasr et al. reports cure rates in traumatic PPC patients of 45% with thoracostomy and 23% after operative intervention. PPC’s elevated mortality rate suggests that further education is needed on common presentations, symptoms, and risk factors to look out for not only on initial trauma evaluation, but more importantly after, as it has been noted to take an hour for tension pathology to develop from PPC. Close monitoring of hemodynamic stability, acute changes in presentation and careful assessment of imaging are all paramount in detecting the progression of PPC to tPPC. Thus, a high index of suspicion should be maintained throughout the trauma assessment for the development of tPPC to improve clinical outcomes.