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Combined pneumothorax and pneumoperitoneum following blunt trauma: an insidious diagnostic and therapeutic dilemma
  1. Salomone Di Saverio1,
  2. Filippo Filicori2,
  3. Kenji Kawamukai3,
  4. Maurizio Boaron3,
  5. Gregorio Tugnoli4
  1. 1Emergency and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna Local Health District, University of Bologna, Bologna, Italy
  2. 2New York Presbyterian Hospital/Weill Cornell Medical College, Department of Surgery, New York, USA
  3. 3Department of Thoracic Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
  4. 4Emergency and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy
  1. Correspondence to Dr Salomone Di Saverio, Emergency and Trauma Surgery Unit, Maggiore Hospital, VIa De' Carbonesi 7, L.Go Nigrisoli, Bologna 40100, Italy; salo75{at}inwind.it

http://dx.doi.org/10.1136/pgmj.2010.110262

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    Introduction

    Pneumoperitoneum following trauma usually indicates the presence of a perforated intra-abdominal viscus and the need for laparotomy.1 Other causes of a pneumoperitoneum demonstrate the alternative routes that air can take into the peritoneal cavity: through the abdominal wall, through the diaphragm, through the female genital tract, and through the retroperitoneum.2–5

    By recognising that air may have taken one of the alternative routes into the peritoneal cavity, an unnecessary laparotomy may be avoided.

    Pneumoperitoneum has also been reported to be a complication of mechanical ventilation,6 likely related to air from the pleural cavity tracking into the peritoneum.7 8

    We present two cases of blunt thoraco-abdominal trauma, with CT findings of massive pneumothorax with large amounts of abdominal free air. These cases show two different possibilities of localisation of intra-abdominal free air associated with traumatic pneumothorax.

    Case 1

    A 21-year-old man was referred to our trauma centre from the casualty department of a local hospital, after falling and being repeatedly kicked by a horse. The patient was haemodynamically unstable at the scene (blood pressure 80/50 mm Hg), tachycardic (114 beats/min (bpm)), and breath sounds were absent on the right side and notably decreased on the left. At the casualty department he underwent immediate needle decompression of the right tension pneumothorax followed by left intercostal drain insertion. The abdomen was slightly distended and tender at palpation, and subcutaneous emphysema was palpable on the upper chest. Focused assessment with sonography for trauma (FAST) was limited by a large amount of intra-abdominal free air. The patient remained unstable after intercostal chest drain (ICD) insertion; he was intubated and referred to us …

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    Footnotes

    • Competing interests None to declare.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.