Héctor Alejandro Carzolio-Trujillo1, Fernando Navarro-Tovar2, César Isaac Padilla-Gómez2, Iván Arturo Hernández-Martínez3, Javier Herrera-Enríquez4. 1. Servicio de Cirugía General, Hospital General de Zona Norte Bicentenario de la Independencia, Secretaría de Salud de Puebla, Puebla, México. Electronic address: fercho_md09@hotmail.com. 2. Servicio de Cirugía General, Hospital General de Zona Norte Bicentenario de la Independencia, Secretaría de Salud de Puebla, Puebla, México. 3. Servicio de Radiología e Imagen, Hospital General de Zona Norte Bicentenario de la Independencia, Secretaría de Salud de Puebla, Puebla, México. 4. Servicio de Cirugía General, Hospital Regional de Poza Rica, Secretaría de Salud de Veracruz, Veracruz, México.
Abstract
BACKGROUND: Pneumomediastinum is the presence of free air around mediastinal structures, which may be spontaneous or secondary, and can occur in 10% of patients with blunt chest trauma, with the Macklin effect being its main pathophysiology. CLINICAL CASE: A 21 year old male, hit by motor vehicle, with alvéolopalatal fracture and blunt chest trauma, who, 72 hrs after admission, shows subcutaneous emphysema in the anterior chest. A simple tomography of the chest and abdomen was performed, finding a pneumomediastinum, bilateral pulmonary contusions and pneumoperitoneum. Oesophageal, tracheobronchial or intra-abdominal viscera injuries were ruled out, establishing the cause of pneumomediastinum and pneumoperitoneum due to the Macklin effect. This required conservative management in intensive care unit, with a favourable clinical course and discharged after a 10 day hospital stay. DISCUSSION: Macklin effect is caused by dissection of air medially along the bronchoalveolar sheath (interstitial emphysema), secondary to alveolar breakdown and extending into mediastinal and other anatomical structures (pneumoperitoneum). It has been documented in blunt trauma, as well as in acute asthma, positive pressure ventilation, or after Valsalva manoeuvres. The imaging method of choice is computed tomography, and its characteristic findings, interstitial emphysema adhering to a bronchus and pulmonary blood vessel. CONCLUSIONS: In the presence of pneumomediastinum and pneumoperitoneum is necessary to rule out oesophageal and tracheobronchial injury before establishing the Macklin effect as its cause. The diagnosis is made with computed tomography and managed conservatively.
BACKGROUND: Pneumomediastinum is the presence of free air around mediastinal structures, which may be spontaneous or secondary, and can occur in 10% of patients with blunt chest trauma, with the Macklin effect being its main pathophysiology. CLINICAL CASE: A 21 year old male, hit by motor vehicle, with alvéolopalatal fracture and blunt chest trauma, who, 72 hrs after admission, shows subcutaneous emphysema in the anterior chest. A simple tomography of the chest and abdomen was performed, finding a pneumomediastinum, bilateral pulmonary contusions and pneumoperitoneum. Oesophageal, tracheobronchial or intra-abdominal viscera injuries were ruled out, establishing the cause of pneumomediastinum and pneumoperitoneum due to the Macklin effect. This required conservative management in intensive care unit, with a favourable clinical course and discharged after a 10 day hospital stay. DISCUSSION: Macklin effect is caused by dissection of air medially along the bronchoalveolar sheath (interstitial emphysema), secondary to alveolar breakdown and extending into mediastinal and other anatomical structures (pneumoperitoneum). It has been documented in blunt trauma, as well as in acute asthma, positive pressure ventilation, or after Valsalva manoeuvres. The imaging method of choice is computed tomography, and its characteristic findings, interstitial emphysema adhering to a bronchus and pulmonary blood vessel. CONCLUSIONS: In the presence of pneumomediastinum and pneumoperitoneum is necessary to rule out oesophageal and tracheobronchial injury before establishing the Macklin effect as its cause. The diagnosis is made with computed tomography and managed conservatively.
Authors: Z Požgain; D Kristek; I Lovrić; G Kondža; M Jelavić; J Kocur; M Danilović Journal: Eur J Trauma Emerg Surg Date: 2017-11-22 Impact factor: 3.693