Tension pneumopericardium after falling from a height.

A 45-year-old woman was brought to the emergency department after sustaining a fall from the sixth floor of a building. She was agitated and complained of chest pain. Examination revealed ecchymosis on the chest, with no subcutaneous emphysema. Her heart rate, blood pressure, respiratory rate and pulse oxygenation level (with supplemental oxygen) were 180 beats/min, 74/32 mmHg, 45 breaths/min and 90%, respectively. Although chest radiography and focused assessment with sonography for trauma were unremarkable, chest computed tomography (CT) revealed right pneumothorax and anterior pneumopericardium (Fig. 1a). Anticipating tension pneumothorax, a right chest tube was inserted. However, hemodynamic instability persisted. Due to pericardial tamponade and the life-threatening circumstances, an emergency thoracotomy was scheduled; a longitudinal incision was made over the tense pericardium via left anterior thoracotomy. A collapsed heart and airflow from the pericardial sac were observed (Fig. 1b). The air within the pericardial sac was speculated to have been trapped by the pneumothorax via a one-way valve mechanism, causing cardiac tamponade. After the surgery, her hemodynamic status improved markedly, and the right chest tube was removed on the fourth operative day. She also had other injuries, including orthopedic fractures that were fixed while she was admitted to the intensive care unit. She recovered and was transferred to the psychiatric unit for further evaluation.

Figure 1

(A) Axial CT scan of the chest showing right pneumothorax, anterior pneumopericardium (black arrow) and mediastinal emphysema. (B) Pericardiotomy via left anterior thoracotomy showing a collapsed heart in the pericardial sac with anterior pneumopericardium (white arrowhead).

Tension pneumopericardium (TPPC) is a rare and often neglected complication of blunt thoracic trauma due to falls from height [1]. It develops due to a pleuropericardial connection between a pneumothorax and the pericardial sac. Air is trapped due to the one-way valve mechanism, causing life-threatening shock of obstructive origin [2, 3]. Although the hyperlucent line around the heart was confirmed retrospectively, its real-time detection was difficult. Although chest CT offers greater accuracy over other imaging modalities [4], logistical issues render it unfeasible in most patients with deep shock. When CT is unavailable, a high index of clinical suspicion is recommended for patients with shock of unclear etiology after falls. Early identification and proper management of TPPC can be lifesaving.