Tension Doesn’t Always Come Alone–– A Case of Tension Pneumothorax With Traumatic Diaphragmatic Hernia Immediately After Blunt Trauma to the Chest

Abstract

Tension pneumothorax (TP) and diaphragmatic hernia (DH) might present with similar symptoms, increasing the probability of missing an underlying diaphragmatic hernia in cases of coexistence. There are a few case reports of DH with tension viscerothorax or fecopneumothorax, but all those had a delayed presentation. However, there is no case report on TP and DH presenting together immediately after trauma. We present a case of coexistence of TP and DH immediately after blunt chest trauma, where ultrasound helped in the identification and management of this life-threatening condition.

Introduction

The tension pneumothorax (TP) is a life-threatening condition that requires immediate needle decompression. 1 The diaphragmatic hernia (DH) is a protrusion of abdominal contents into the thoracic cavity through a defect in the diaphragm. Around 12%–66% of diaphragmatic injuries are missed at initial screening. 2 The clinical features are absent breath sounds with reduced chest expansion, the presence of bowel sounds on the affected side of the thorax, and respiratory distress with paradoxical abdominal movement. Laparoscopy or thoracoscopy can help in difficult diagnosis cases. 3 But these are of no help in the emergency room setup when it occurs with TP. We are presenting a case of TP and DH in a patient with blunt trauma to the chest. Caution is essential when inserting an intercostal chest drain.

Case Presentation

A 33-year-old male was brought to the emergency department with an alleged history of falls from a height of about two storeys that happened 4 hours back. He presented with chief complaints of shortness of breath and chest pain. On examination, the airway was patent, and he was able to speak in complete sentences. His respiratory rate was 45 breaths/min, SpO2 90% in room air, heart rate 140 beats/min, and blood pressure (BP) 87/67 mmHg. Oxygen was supplemented through a face mask at 4 L/min. There was decreased chest expansion and absent breath sounds on the left side. Gradually, his SpO2 started falling despite oxygen supplementation, and he was not able to speak a complete sentence. So, oxygen was supplemented through a non-rebreather mask at 10 L/min that maintained the SpO2 at 90%. However, BP gradually fell to 70/50 mmHg. Chest compression test was positive, neck veins distended, and the trachea deviated to the right side. A clinical diagnosis of TP was made, and needle thoracostomy was attempted in the left 5 ^th intercostal space (ICS) at the anterior axillary line. But the gush of air was absent. So, another attempt was made at the 2 ^nd ICS at the midclavicular line with a successful gush of air, and BP improved to 90/60 mmHg. A 28-FG intercostal chest drain (ICD) was then inserted in the 5 ^th ICS with some manipulation. There was air column movement and improvement in BP to 98/60 mmHg and SpO2 to 94% with 10 L/min oxygen flow. However, breath sound was still reduced on the left side. Point of care ultrasonography found the diaphragm at the 5 ^th ICS and an echogenic tissue (probably stomach as it was muscular) was seen above the diaphragm. An immediate bedside chest X-ray was done, which showed herniation of about two-thirds of the stomach into the thorax ( Fig. 1 ). The computed tomography (CT) scan of the chest showed diaphragmatic discontinuity, collar sign, and herniation of the stomach into the thorax (Figs. 2 and 3). The patient was transferred to the operating room for repair of the DH. He was hemodynamically stable and maintained SpO2 in room air after surgical repair and was discharged from the hospital after five days.

Fig. 1 . Chest X-ray (anteroposterior view, AP) showing diaphragmatic herniation with mediastinal shift to right side. (A) Deviation of trachea and mediastinum to right side; (B) Herniation of stomach into left hemithorax; (C) Right hemidiaphragm in normal position.

Fig. 2 . Computed tomography of thorax (axial views). (A) Mediastinal window; (B) Lung parenchymal window. Arrow (1) Herniated part of stomach in left hemithorax; Arrow (2) Nasogastric tube in stomach; Arrow (3) Herniated stomach; Arrow (4) Deviation of mediastinum to right.

Fig. 3 . Computed tomography of thorax (sagittal view). Arrow (1) Diaphragm; Arrow (2) Herniation of stomach through rent in diaphragm; Arrow (3) Left gastric vessels.

Discussion

Al Skaini et al. 4 reported a case of tension viscerothorax in a 30-year-old male who presented with respiratory distress two years after a car accident. The CT scan was normal when he presented to the hospital after that accident. The authors explained that a small diaphragmatic injury caused by the accident was missed at the initial presentation. A continuous movement of the diaphragm might hinder the healing of that injury, leading to the current condition.

Chen et al. 5 reported a case of left-sided chest stab injury in a 22-year-old male. The patient presented lately with respiratory distress and sepsis. There was hydropneumothorax with mediastinal shift in the CT scan. An ICD was inserted, and a large amount of bowel contents was drained. The laparoscopy found left DH containing splenic flexure of the colon with perforation, causing left hemithorax contamination. Postoperative recovery was uneventful, and the patient was discharged from the hospital.

Pilate et al. 6 reported a case of blunt trauma to the chest following a fall from stairs in a 92-year-old male. There was left TP with pneumoperitoneum on chest X-ray. A needle decompression followed by ICD insertion was done. CT scan revealed left diaphragmatic rupture, and conservative management was initially decided. But later, there was drainage of brownish liquid through the ICD. Repeat CT showed herniation of the transverse colon through the diaphragmatic defect and was repaired surgically.

We are reporting a case with TP and DH presenting together immediately after trauma. Usual teaching is immediate decompression of TP without waiting for radiological confirmation. 4 It may be harmful to insert an ICD in tension gastrothorax. 6 Al Skaini et al., 4 suggest a chest X-ray before ICD insertion if time permits to distinguish between the two conditions. From our experience, we suggest doing an ultrasonography scan to look for the position of the diaphragm and any herniation before ICD placement.

In conclusion, ultrasound use before insertion of intercostal chest drain can prevent complications in traumatic diaphragmatic hernia with tension pneumothorax.