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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.
(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)

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kumar 1973 Denmark	Isolated case	Case report	Survival		Isolated case
Demetriades 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
Pasic 1999 Germany	Isolated case	Case report	Survival		Isolated case
Rashid 1999 Sweden	Isolated case	Case report	Survival	Stable patient but underwent surgery once diagnosis was made by CT

Comment(s)

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.

Clinical 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

1. Kumar V. Traumatic Pneumopericardium . Injury 4 (3): 225, 1973 Feb
2. Demetriades D. Charalambides D. Pantaowitz D. Lakhoo M. Pneumoperitoneum Following Penetrating Chest Injuries. Archives of Surgery. 125 (9): 1187-9, 1990 Sep
3. Pasic M. Hetzer R. Pneumopericardium after Thoracic Stab Wound. European Journal of Cardiothoracic Surgery. 15 (2): 224, 1999 Feb
4. Rashid MA, Wikstrom T. Ortenwall P . Pneumopericardium and Pneumoperitoneum after Penetrating Chest Injury. European Journal of Surgery. 165 (3): 278-9, 1999 Mar.