Adolescent pneumopericardium and pneumomediastinum after motor vehicle crash and ejection

A 15 year old male was an unrestrained passenger in a high speed motor vehicle crash followed by ejection. The patient was noted to have evidence of bilateral pneumothorax upon arrival in the Emergency Department. Bilateral chest tubes were placed under sterile conditions; however, the left pneumothorax remained, and a second left chest tube was placed. Repeat chest radiographs revealed extensive subcutaneous emphysema, pneumomediastinum, and pneumopericardium. Needle aspiration of the pericardium returned significant quantities of air, an immediate improvement in blood pressures followed. An 18-gauge triple lumen catheter was placed into the pericardial space for additional withdrawal of air via syringe. Mechanisms have been proposed to explain the development of tension pneumopericardium after chest trauma. Early diagnosis is crucial, and may be found on initial chest radiographs. Computed tomography is also an effective method for evaluating the presence of air in the pericardial space and may assist in establishing the diagnosis. Tension pneumopericardium requires immediate recognition and decompression to prevent cardiac tamponade with a fatal circulation collapse, an entity that is as serious as the tamponade resulting from hemopericardium. Traumatic pneumopericardium is rare, but can be a complicated finding associated with high-speed blunt chest trauma. Patients with evidence of pneumopericardium should be closely monitored, particularly those supported by positive pressure ventilation.